RESIDENCY PROGRAM HOUSE STAFF ORIENTATION AND POLICY MANUAL

RESIDENCY PROGRAM
HOUSE STAFF ORIENTATION
AND POLICY MANUAL
2014-2015
1
Contents
MISSION ....................................................................................................................................................................4
PHILSOPHY ................................................................................................................................................................4
CONTACT INFORMATION ............................................................................................................................................5
PROGRAM ADMINISTRATION................................................................................................................... 5
PROGRAM FACULTY ................................................................................................................................. 6
FAMILY MEDICINE RESIDENTS................................................................................................................ 7
RESIDENT APPOINTMENTS ........................................................................................................................................8
Qualifications............................................................................................................................................ 8
Essential Job Functions ........................................................................................................................... 8
Appendix A .................................................................................................................................................................... 10
Resident Transfer................................................................................................................................... 11
ACGME COMPETENCIES ..........................................................................................................................................12
EDUCATIONAL PROGRAM.........................................................................................................................................14
Core Curriculum ..................................................................................................................................... 14
Adult Medicine........................................................................................................................................ 17
Women’s Health ..................................................................................................................................... 23
Children’s Health.................................................................................................................................... 27
Maternity................................................................................................................................................. 33
Surgery .................................................................................................................................................... 38
Musculoskeletal & Sports Medicine ..................................................................................................... 42
Critical & Emergency Care ..................................................................................................................... 46
Human Behavior & Mental Health ........................................................................................................ 50
Community and Occupational Medicine ............................................................................................... 54
Care of the Skin...................................................................................................................................... 57
Diagnostic Imaging and Nuclear Medicine ........................................................................................... 60
Practice Management............................................................................................................................ 63
Scholarly Activity..................................................................................................................................... 66
Rotation Schedules for 2014-2015 Academic Year............................................................................ 68
RESIDENT EVALUATION & ADVISING ........................................................................................................................69
Evaluation ............................................................................................................................................... 69
Advising................................................................................................................................................... 69
In-Training Exam..................................................................................................................................... 69
Promotion ............................................................................................................................................... 69
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Resident Discipline: Due Process, Remediation, & Probation ............................................................ 70
Program Evaluation................................................................................................................................ 71
Annual Review of Program Effectiveness ............................................................................................. 71
RESIDENT SUPERVISION, WORK ENVIRONMENT, & DUTY HOURS ............................................................................72
Supervision ............................................................................................................................................. 72
Work Environments ................................................................................................................................ 73
Inpatient Service: ......................................................................................................................................................... 73
Geriatrics Inpatient Service ......................................................................................................................................... 79
Maternity Service ......................................................................................................................................................... 85
Night Hospital Physician Service & Night Hospital Physician Home Call ................................................................. 88
The Family Health Center ............................................................................................................................................ 91
Ambulatory Rotations .................................................................................................................................................. 95
Hospital Based Rotations ............................................................................................................................................ 96
Documentation....................................................................................................................................... 97
Call and Duty Hours ............................................................................................................................... 98
OTHER PROGRAM POLICIES AND PROCEDURES .................................................................................................... 100
Absences: Vacation, Sick Leave, and Other Leave ............................................................................ 100
Leave Policies ............................................................................................................................................................. 100
Backup Schedule ................................................................................................................................. 105
Benefits................................................................................................................................................. 106
Licensure .............................................................................................................................................. 106
Moonlighting ......................................................................................................................................... 106
Electives................................................................................................................................................ 107
Dress Code ........................................................................................................................................... 108
Conference Attendance ....................................................................................................................... 109
Chief Resident Elections ...................................................................................................................... 109
Use of Internet and Social Networking Sites ...................................................................................... 109
Physician in Training (PIT) Permit........................................................................................................ 116
Requirements ....................................................................................................................................... 118
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MISSION
The mission of the Family Medicine Residency Program of the University of Texas Health Science Center at San Antonio is to
train balanced physicians. Excellent physicians treat their patients using an approach that considers the biological basis of
disease within the framework of the patient’s social context, mental health, and spiritual needs.
Residents and faculty are encouraged to model a balanced, healthy lifestyle. The program’s training prepares residents to meet
the primary care needs of the population and to develop skills to flourish in the rapidly changing medical industry. Residents
are trained to care for patients in all phases of life.
Our training sites focus on caring for an urban, underserved population, but our residents are prepared to be successful in a
variety of practice settings.
PHILSOPHY
Our residency training emphasizes:
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Continuity practice in ambulatory setting—First year residents average over 2 half-days per week in the Family Health
Center.
Family Physicians trained by Family Physicians—70% of the curriculum is taught by Family Medicine Faculty.
Excellence—Scholarly efforts are expected to focus on the resident’s vision of his/her future practice.
Commitment to the Community—Residents become immersed in and learn to serve the community in which we live and
practice.
Integrity—Adherence to sound moral and ethical principles in all aspects of professional work is the essential
foundation of medical practice.
Communication skills—Verbal and written communication skills are the cornerstone of quality patient-centered medical
care.
Central to our mission is the importance of the family and the community in the context of patient care. We have a profound
belief that social and psychological factors are as important as biomedical factors. Well trained Family Physicians must be able
to communicate well and wisely, use the doctor-patient relationship in therapeutic ways and understand the overall context of
their patients’ lives and the health needs of the communities they serve.
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CONTACT INFORMATION
PROGRAM ADMINISTRATION
Office
Pager/Cell
Email
567-4553
n/a
[email protected]
358-3931
373-9521
[email protected]
n/a
776-5583
[email protected]
567-4550
235-1524
[email protected]
358-3905
385-4753
[email protected]
Chairman
Carlos Robert Jaén, MD, PhD
Leadership
Mark T. Nadeau, MD, MBA, FAAFP
Residency Program Director
Marcy Wiemers, MD
Associate Program Director
Ramin Poursani, MD
Medical Director, Family Health Center
Sandra Burge, PhD
Behavioral Medicine Director
Cristián Fernandez-Falcón, MD
[email protected]
Inpatient Service Director
Program Staff
Cathleen Brannen
Manager, Academic Programs
Janie Treviño
Program Coordinator
Juliana Monteiro
Program Coordinator
358-3931
669-3683
358-6646
358-3888
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[email protected][email protected]
347-8986
[email protected]
PROGRAM FACULTY
Office
Pager/Cell
E-mail
Muhammad Akram, MD
592-0150
235-1150
[email protected]
Fozia Ali, MD
358-3905
513-2019
[email protected]
Nehman Andry, MD
567-4566
Oralia Bazaldua, Pharm D
358-3905
235-0718
[email protected]
Walter Calmbach, MD
358-3930
235-0110
[email protected]
Betty Corona, MSN, FNP-C
567-4550
235-0059
[email protected]
Sally Dunlap, PhD
358-3905
235-3713
[email protected]
235-1659
[email protected][email protected]
Nida “Joy” Emko, MD
Robert Ferrer, MD
358-3885
235-4531
[email protected]
Margaret Rosina Finley, MD
358-3200
235-1064
[email protected]
235-0078
[email protected]
Lindy Ivy, MD
David Katerndahl, MD
358-3998
235-0364
[email protected]
K. Ashok Kumar, MD
567-4555
235-0416
[email protected]
Stella Koretsky, MD
567-4550
235-0522
[email protected]
W. Ross Lawler, MD
358-3930
235-0363
[email protected]
Margaret Mann-Zeballos, MD
[email protected]
Claudia Miller, MD
567-7762
219-6618
[email protected]
Cordelia Moscrip, MD
592-0150
553-0163
[email protected]
Rodolfo Navarro, MD
358-3905
513-1292
[email protected]
Manuel Oscos-Sanchez, MD
358-3920
235-6461
[email protected]
Robert Parker, MD
358-3200
715-0718
[email protected]
Neela Patel, MD
358-3200
513-0639
[email protected]
Lewis Rose, MD
358-3934
235-0483
[email protected]
Saima Siddiqui, MD
235-1052
[email protected]
Juan Jose Treviño, MD
235-1063
[email protected]
James Tysinger, PhD
567-4577
235-0055
[email protected]
Richard Usatine, MD
358-3200
235-1107
[email protected]
Yanping Ye, MD
358-3200
235-3884
[email protected]
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FAMILY MEDICINE RESIDENTS
Pager
E-mail
Chief Residents
Sandra Herman, MD
Maria Montañez, MD
Kassie Soefje, MD, Teaching Chief
203-9947
203-9621
203-2029
[email protected][email protected][email protected][email protected]
Reem Hadi, MD
Patricia Lacsina, MD
Elizabeth Lang, MD
Gisela Lopez-Payares, MD
Rachel Myers, MD
Teny Philip, MD
Paula Shelton, MD
203-6915
203-7150
203-7338
203-8692
203-6235
203-7343
203-8862
203-7125
Jennifer Smith, MD
203-6276
[email protected]
203-0217
[email protected]
Albelyh Del Rosario, MD
203-0794
[email protected]
Mary Anne Estacio, DO
203-1303
[email protected]
Assaf Fesseha, MD
203-0741
[email protected]
Shwe Oo, MD
203-9390
[email protected]
Janessa Perez, MD
203-0086
[email protected]
Maurellen Rabago, MD
203-0768
[email protected]
Edmond Shih, MD
203-6733
[email protected]
Amy Singer, DO
203-1715
[email protected]
Anna Tenorio, MD
203-2169
[email protected]
Cheryll Udani, MD
203-1191
[email protected]
Anjuli Vasquez, MD
203-1964
[email protected]
PGY3 Residents
Angelica Davila, MD
[email protected][email protected][email protected][email protected][email protected][email protected][email protected]
PGY2 Residents
Yasmeen Agha, MD
David Aldrete, MD
PGY1 Residents
Crystal Amadi, MD
[email protected]
Maria Babaran, MD
[email protected]
Robert Baillieu, MD
[email protected]
Jane Chandy, DO
[email protected]
Jeremy Day, MD
[email protected]
Rocio De Los Santos, MD
[email protected]
Sujan Gogu, DO
[email protected]
George Golod, MD
[email protected]
Taleen Khalaf, MD
[email protected]
Miguel Palacios, MD
[email protected]
Merin Sabu, MD
[email protected]
Hanh Trinh, MD
[email protected]
Sida Yan, MD
[email protected]
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RESIDENT APPOINTMENTS
The UTHSCSA Family Medicine Residency Program has 13 PGY1, 13 PGY2, and 12 PGY3 positions, for a total of 38 residents
for the 2014-2015 academic year.
Qualifications
Candidates must be US citizens, US residents, or demonstrate eligibility for employment in the US prior to ranking. Candidates
must have recent significant clinical experience—preferably in the US. They must be able to demonstrate a true commitment to
family medicine, be able to perform the essential job functions outlined in this policy manual, and be eligible for a physician in
training (PIT) certificate in Texas. If from a non-LCME accredited school, candidates should be ECFMG certified. We look at the
overall application of the candidates and how each applicant will fit into our program to help us fulfill our mission.
Essential Job Functions
Essential Abilities Requirements for Appointment, Reappointment, Retention and Certification for GME at UTHSCSA.
Essential abilities are academic performance requirements that refer to the physical, cognitive, and behavioral abilities required
for satisfactory completion of all aspects of a graduate medical curriculum and the development of personal attributes required
by the faculty of all residents at certification.
The essential abilities required by the curriculum are in the following areas: intellectual (conceptual, integrative, and
quantitative abilities for problem solving and diagnosis), behavioral and social aspects of the performance of a physician,
communication, motor, and sensory. These are attributes each resident physician must possess, and the use of a third party for
the fulfillment of these attributes is not adequate.
Individual residency programs may require different specific abilities of their residents, and these may vary as appropriate to the
practice requirements of the specialty. When a resident who requires assistance enters a residency program, it is expected that
all necessary accommodations will be detailed and agreed to by the program before he/she begins training.
Residents must be legally authorized to practice in all health care clinical training sites.
Intellectual Abilities
Residents must be able to comprehend and learn factual knowledge from readings and didactic presentations, gather
information independently, analyze and synthesize learned material, and apply information to clinical situations. Residents
must be able to develop habits of lifetime learning. They must be able to develop sound clinical judgment and exhibit wellintegrated knowledge about the diagnosis, treatments, and prevention of illness within their scope of practice. They must be
comfortable with uncertainty and ambiguity in clinical situations and seek the advice of others when appropriate.
Behavioral, Social, and Professional Abilities
Residents must possess the emotional maturity and stability to function effectively under the stress that is inherent in medicine
and to adapt to circumstances that are unpredictable or that change rapidly. They must be able to interact productively,
cooperatively, and in a collegial manner with individuals of differing personalities and backgrounds, and be active contributors
to the process of providing health care by demonstrating the ability to engage in teamwork and team building. They must
demonstrate the ability to identify and set priorities in patient management and in all aspects of their professional work. They
must be punctual and complete their work in a timely manner.
Residents must be capable of empathetic responses to individuals in many circumstances, and be sensitive to social and
cultural differences. They must exhibit an ethic of professionalism, including the ability to place others’ needs ahead of their
own. The must exhibit compassion, empathy, altruism, integrity, responsibility, and tolerance, as well as demonstrate the ability
to exercise the requisite judgment in the practice of medicine.
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Communication Skills
The practice of medicine emphasizes collaboration both verbally and in writing among physicians, other health care
professionals, and the patient. Residents must be able to communicate effectively with patients, including: gathering
information appropriately; explaining medical information in a patient-centered manner; listening effectively; recognizing,
acknowledging, and responding to emotions; and exhibiting sensitivity to social and cultural differences. They must be able to
communicate effectively and work cooperatively with supervisors, other residents, and all other health care team members.
Residents must be able to write clear, coherent, and legible notes and correspondence. Residents must be able to speak in a
clear, coherent, and easily understood voice. Keyboarding is also an essential job function of the residency program.
Motor Skills
Residents must have sufficient physical dexterity to master technical and procedural aspects of patient care. They must have
sufficient strength to perform the essential duties of their specialty and must have adequate physical stamina and energy to
carry out taxing duties over long hours (general outlined by the ACGME duty hour requirements).
Sensory Abilities
Residents must be able to gather information with all senses—especially sight, hearing, smell, and touch—in order to gather a
medical and psychosocial history, perform a physical examination, and diagnose and treat patients.
ADDITIONAL Specific Essential Job Functions Required by the Family Medicine Residency Program:
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Take a history and perform a physical examination
Use sterile technique and universal precautions
Perform cardiopulmonary resuscitation
Perform central line placement, paracentesis, chest tube insertion, nasogastric tube insertion, foley catheter insertion,
joint aspirations and injections.
Move throughout the clinical site and hospitals to address routine and emergent patient care needs
Deliver a baby and learn to repair an episiotomy
Assist at operations
Communicate with patients and staff, verbally and otherwise in a manner that exhibits good professional judgment and
good listening skills and is appropriate for the professional setting. Verbal communication must be easily understood
by patients and co-workers. Written communication must be grammatically correct.
Demonstrate timely, consistent and reliable follow-up on patient care issues such as laboratory results, patient phone
calls, or other requests (see appendix A)
Input and retrieve computer data through a keyboard and mouse, and read a computer screen.
Must be able to input data efficiently enough to meet required accuracy and volume standards for patient care.
Read charts and monitors.
Perform documentation procedures such as chart dictation and other paperwork in a timely fashion, in emergency,
ambulatory, and hospital settings.
Demonstrate organizational skills eventually required to care for 10 or more outpatient cases per half day.
Take call for the practice or service, which requires inpatient admissions and work stretched up to 28 hours.
Present well-organized case presentations to other physicians or supervisors.
Participate by completing all duties, including giving and receiving feedback, and completing all required rotations.
Participate in and satisfactorily complete all required rotations in the curriculum.
Perform office and hospital procedures expected of a family physician (LP, thoracentesis, colposcopy, excision,
cryotherapy, circumcision, paracentesis, chest tube insertion, nasogastric tube insertion, foley catheter insertion, joint
aspirations and injections).
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Appendix A
Lab Results Protocol
For “Critical Values” (i.e. those values that require immediate attention or may be potentially life threatening), the
laboratory/radiology will:
(i) Page the physician,
(ii) Ask for a verbal “read-back” from the physician, and
(iii) Record the conversation.
In addition to the requirements above, the physician will:
(i)
(ii)
(iii)
Contact the patient and inform them of the Critical Value;
Draft an FHC Patient Communication note memorializing the communication with the patient; and
Forward the FHC Patient Communication note to his or her attending via SHM.
For “Abnormal Values” that do not fall into the Critical Value category (as defined above):
(i) The physician should review the results in their Inbox on Sunrise.
(ii) The physician must “Annotate” or “Annotate and Acknowledge” the result within seventy-two (72) hrs.
(iii) Interns must also send a SHM to their assigned attending to verify lab results in addition to the “Annotate and
Acknowledge” requirement above.
When critical/abnormal values require notification of patient, the physician should document what measure they took in an FHC
Patient Communication Note. Physician can either document that they (i) called patient, (ii) mailed a letter, or (iii) were unable to
reach patient. Each attempt at contact should be documented in a Patient Communication Note. Interns should also forward
the note to their attending(s).
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Resident Transfer
The UTHSCSA Family Medicine Residency Program follows the UTHSCSA GME Policy 4.3.1 RESIDENT TRANSFER:
Residents who apply for transfer from another GME program are subject to all elements of the Resident Selection and
Appointment Policy, as well as additional requirements. Per ACGME requirements,
1. Before accepting a resident who is transferring from another program, the UTHSCSA Program Director must obtain
written or electronic verification of previous educational experiences and a summative competency-based performance
evaluation of the transferring student.
2. A UTHSCSA Program Director must provide timely verification of residency education and summative performance
evaluations for residents who leave the program prior to completion.
In addition to the requirements above, the Texas Medical Board (TMB) mandates a postgraduate resident permit for all
residents entering Texas programs. Residents will not be allowed to enroll in programs until they have been issued a permit or
a Texas medical license.
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ACGME COMPETENCIES
The national Accreditation Council for Graduate Medical Education (ACGME) requires that all residency programs—regardless of
specialty—ensure their residents master skills in the six general competencies to the level expected of a new practitioner.
Toward this end, programs must define the specific knowledge, skills and attitudes required and provide educational
experiences as needed in order for their residents to demonstrate the competencies. Residents should know these six common
program competencies. The competencies are the basis for all aspects of the educational program, including program goals and
objectives, evaluation, promotion, and graduation.
PATIENT CARE
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health
problems and the promotion of health.
MEDICAL KNOWLEDGE
Residents must demonstrate knowledge about established and evolving biomedical, clinical, and epidemiological and socialbehavioral sciences, as well as the application of this knowledge to patient care.
PRACTICE-BASED LEARNING AND IMPROVEMENT
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific
evidence, and continuously to improve patient care based on constant self-evaluation and lifelong learning. Residents are
expected to develop skills and habits to be able to meet the following goals:
• Identify strengths, deficiencies, and limits in one’s knowledge and expertise
• Set learning and improvement goals
• Identify and perform appropriate learning activities
• Systematically analyze practice using quality improvement methods
• Implement changes with the goal of practice improvement
• Incorporate formative evaluation feedback into daily practice
• Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems
• Use information technology to optimize learning
• Participate in the education of patients, families, students, residents, and other health professionals
INTERPERSONAL AND COMMUNICATION SKILLS
Residents must demonstrate interpersonal and communication skills that result in effective exchange of information and
collaboration with patients, their patients’ families, and health professionals. Residents are expected to:
• Communicate effectively with patients, families, and the public—as appropriate—across a broad range of socioeconomic
and cultural backgrounds
• Communicate effectively with physicians, other health professionals , and health-related agencies
• Work effectively as a member or leader of a health care team or other professional group
• Act in a consultative role for other physicians and health professionals
• Maintain comprehensive, timely, and legible medical records, if applicable.
PROFESSIONALISM
Residents must demonstrate a commitment to carrying out professional responsibilities and adherence to ethical principles.
Residents are expected to demonstrate:
• Compassion, integrity, and respect for others
• Responsiveness to patient needs that supersedes self-interest
• Respect for patient privacy and autonomy
• Accountability to patients, society, and the profession
• Sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age,
culture, race, religion, disabilities, and sexual orientation
SYSTEMS-BASED PRACTICE
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as
the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:
• Work effectively in various health care delivery settings and systems relevant to their clinical specialty
• Coordinate patient care within the health care system relevant to their clinical specialty
• Incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care as
appropriate
• Advocate for quality patient care and optimal patient care systems
• Work in interprofessional teams to enhance patient safety and improve patient care quality
• Participate in identifying system errors and implementing potential systems solutions.
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What do the competencies look like in patient interaction?
Putting yourself in the shoes of the patient, what are your expectations upon first meeting your new doctor?
THE PATIENT’S EXPECTATIONS
The physician greets you with a handshake, makes eye
contact, and sits to listen to your concerns and symptoms.
THE ACGME GENERAL
COMPETENCY
Patient Care
(compassionate, appropriate, and
effective)
The physician knows what illness you are describing and has
knowledge of what specific exams and tests will help with the
diagnosis.
Medical Knowledge
The physician listens to you and your family members and is
able to discuss the condition candidly and effectively with you
and those that you are being referred to for further evaluation
Interpersonal & Communication Skills
The physician makes you feel that they are qualified to help you
and will carry this out with the highest degree of confidentiality,
ethical, and moral standards.
Professionalism
The physician is up to date on the latest in their field and is
involved in a lifelong learning process that includes feedback
from previous similar cases that they have been involved with.
Practice-Based Learning and
Improvement
The physician knows enough about your healthcare system and
insurance that they (or their designee) can help you with
understanding costs of tests, treatments and further examinations.
Systems-based Practice
This scenario is designed to heighten your awareness of the general competencies and to emphasize their practical
use and validity in practice. The issues are simplified to help trigger recall of the competencies.
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EDUCATIONAL PROGRAM
The Family Medicine Review Committee (FMRC) has defined what the ACGME competencies mean for our specialty. The
residency is committed to full implementation of these competencies and to making our educational program outcomes-based.
In this regard, our program leadership has designed the educational program to follow the structure of the ACGME
competencies within the FMRC-defined curricular areas.
Core Curriculum
This is the set of common objectives for most clinical and nonclinical learning experiences.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
1. Demonstrate the ability to access, interpret and
apply
PGY1: 1, 2, 3,
Patient
Care
Family Medicine residents will
learn to appropriately manage
patients.
Medical Knowledge
Family Medicine residents will
attain medical knowledge to
practice the full spectrum of
family medicine.
Practice-Based Learning and
Improvement
Family Medicine residents will
learn to efficiently lead and
continuously improve the
multiple elements of health
care delivery within the
practice of family medicine.
Evidence Based Medicine.
2. Demonstrate awareness of personal gaps
in knowledge or skills and the ability to
address those deficits.
4, 5
PGY2: 6
3. Incorporate formative feedback into daily
practice.
4. Contact supervising resident or faculty in a
timely manner with any questions, need for
assistance, or need for supervision to
maintain safe patient care.
5. Demonstrate effective team
participation in educational
sessions.
6. Display initiative and leadership by
effectively teaching others, including
patients, families, fellow residents, other
learners, and members of the healthcare
team.
Interpersonal and
Communication Skills
Family Medicine residents
1. Document patient care in concise and
organized clinical notes.
2. Use HIPAA standards to communicate with
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PGY1: 1, 2, 3,
4,5
will learn to counsel their
patients with respect to
their healthcare needs.
patients’ families in a patient centered manner
3. Use an organized standard sequence to
present patients to faculty, consultants,
colleagues and other learners.
PGY2: 6, 7
4. Communicate orders clearly to nurses and other
members of the healthcare team.
Family Medicine residents
will learn to communicate
effectively with faculty
physicians, consultants,
fellow residents, other
learners and other members
of the healthcare team.
5. Provide problem focused handoffs to
colleagues to ensure patient safety.
6. Use patient centered communication skills
to identify patient concerns and
expectations and to explain to
patients their conditions and management
options
7. Communicate to patients the risks and benefits
of therapy for medical conditions and obtain
informed consent.
Professionalism
Family Medicine residents will
demonstrate behaviors
consistent with the ethical and
responsible practice of patient
centered care.
1. Dress appropriately according to the Family
Medicine
Residency Manual or the expectations of the
specialty service.
2. Arrive to all professional obligations in
a timely manner.
3. Demonstrate a respectful approach to
interactions with fellow residents, other
learners, faculty, nurses, office staff,
patients and their families, and other
members of the healthcare team.
PGY1: 1 ,2, 3,
4, 5, 6
PGY2: 7
PGY3: 8
4. Demonstrate sensitivity to patient culture,
gender, age, disability, sexual preference
and decisions regarding pregnancy and
newborn.
5. Use chaperones appropriately in clinical
settings.
6. Respond to all pages, emails,
professional communications and
requests for admission or consult in a
timely manner.
7. Demonstrate appropriate use of an
interpreter in clinical interactions.
8. Demonstrate the ability to take responsibility for
personal, professional mistakes and the ability to
disclose them appropriately to patients.
Systems-Based Practice
Family Medicine residents
will learn to identify the
1. Identify the components of an acceptable
consult to a specialist, including communicating a
clear clinical question.
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PGY1: 1, 7
structure and operations of
health organizations and
systems and the effective
role of the family physician
within that system.
Family Medicine residents will
become effective supervisors
for junior learners and
productive leaders of teams
responsible for patient care.
2. Identify resources available in the community
to enhance patient care, such as home-health
providers, social work agencies, WIC, ECI, etc.
PGY2: 2, 3, 4,
3. Provide constructive, formative feedback on
learning experiences and about supervising
faculty and residents.
PGY2 (mid-yr):
6, 9
12, 13, 14, 15,
4. Demonstrate the ability to work in an
interprofessional team to enhance patient
safety and improve quality of care.
16
5. Demonstrate the ability to advocate for a
patient’s welfare while balancing the
business realities of practicing medicine.
PGY3: 5, 8,
6. Describe the different healthcare funding
sources available in San Antonio
7. Use the EMR efficiently and effectively for all
patient care interactions
8. Describe the regulatory statues that different
facility types (nursing homes, hospitals,
laboratories, etc) must adhere to for standard
practice.
9. Describe and list differences among a
Power of Attorney for Healthcare,
Advance Directives, DNR/DNI, and Out
of Hospital DNR/DNI.
10. Describe the essential features of the Medical
Practice Act and state regulation of medical
practice.
11. Demonstrate the ability to effectively lead a
team of junior learners in a patient care
setting.
12. Has the knowledge and ability necessary to
complete all tasks and assignments for the
rotation without direct faculty supervision.
13. Demonstrates the ability to delineate
expectations to supervisee
14. Demonstrates the ability to assess deficits
of supervisee in a specific setting.
15. Demonstrates the ability and willingness to
provide constructive feedback to junior
learners.
16. Demonstrates an awareness of his/her
limitations and a willingness to ask for help
when needed.
16
10, 11
Adult Medicine
The curriculum must include at least 8 months of adult medicine; 6 of these months must be inpatient experiences.
Goals for Graduation
Patient Care
Family Medicine residents
will learn to appropriately
manage adult patients in the
inpatient, outpatient and
nursing home settings.
Learning Objectives
Level at which
competence is
required
1. Given an adult presenting for a wellness visit:
PGY1: 1a, 1b,
a. Perform a complete and reproducible
age- appropriate history including social
history, family history, psychosocial
assessment and identification of risk
factors for chronic disease.
b. Perform a complete and reproducible
age appropriate physical exam.
c.
Follow recommendations on ageappropriate preventive screening
evaluations.
d. Provide age appropriate immunizations.
e. Provide age appropriate health education
f.
Manage any abnormal findings in the
history and/or the physical exam as
outlined by the evaluation of an acute
complaint
2. Given an adult with an acute complaint
a. Perform a reproducible history and
physical exam
b. Develop a differential diagnosis
c.
Create an evidence based evaluation
and management plan, including
indications for hospitalization
d. Use standard guidelines to order and
interpret the results of diagnostic
studies (labs, Xrays, EKGs, etc)
3. Given an adult with a chronic condition
a. Perform a reproducible history and
physical exam
b. Identify an appropriate clinical
practice guideline, if available
c.
Create an evidence based evaluation and
17
1c, 1d, 1e, 1f;
2a; 3a, 3b, 3c;
4a, 4d, 4e, 4j
PGY2: 2b, 2c,
2d; 3d, 3e, 3f;
4b, 4c, 4f, 4g,
4h; 5a, 5d; 6
PGY3: 4i, 4k;
5b, 5c
management plan
d. Use standard guidelines to order and
interpret the results of diagnostic
studies (labs, Xrays, EKGs, etc…)
e. Identify and manage complications of
chronic disease
f.
Address the special healthcare
needs of adults with disabilities
4. For the hospitalized adult patient,
a. Perform a reproducible
comprehensive history and physical
exam
b. Develop a differential diagnosis
c.
Create an evidence based evaluation
and management plan
d. Use standard guidelines to order and
interpret the results of diagnostic
studies (labs, Xrays, EKGs, etc…)
e. Apply standard inpatient care protocols as
indicated. (i.e. DVT Prophylaxis, GI
prophylaxis etc)
f. Perform procedures necessary to diagnosis
and treat patient’s condition (paracentesis,
thoracentesis, lumbar puncture)
g. If the patient’s medical condition
worsens, use standard protocols to
stabilize the patient.
h. Determine level of care needed and
arrange proper transfers and consultations
indicated in a timely manner
i.
Determine criteria for discharge
j.
Arrange and coordinate discharge,
including appropriate follow up
k. If terminally ill, provide palliative care to
the patient according to the patient’s and
family’s wishes.
5. For elderly patients in all healthcare settings as
appropriate (nursing home, ambulatory,
inpatient),
a. Perform a standard geriatric assessment to
include a comprehensive history and
physical, ADLS, IADLs, MMSE, Clox,
18
Geriatric Depression Scale, fall risk
assessment, assessment of decision
making capacity, polypharmacy and
psychotropic drug review.
b. Recognize and intervene in prevention of
the hazards of nursing home and
hospitalizations: deconditioning, pressure
ulcers, foley catheter use, falls
c.
Recognize and manage geriatric
syndromes including dementia, delirium,
and depression.
d. Develop a complete, prioritized problem
list identifying relevant clinical,
psychological, functional, mental and
social problems.
6. Discuss Advanced Directs and Power of Attorney for
Healthcare with adult and geriatric patients in all
healthcare settings.
Medical Knowledge
Family Medicine residents
will learn about common
acute and chronic conditions
that effect adult and geriatric
patients.
List the components of an age-appropriate wellness
visit for adults and geriatric patients.
2. For common adult acute complaints*, list the
presenting symptoms & physical exam findings, the
common causes, and recite the outpatient work up
and management.
3. For common adult chronic conditions*, describe the
pathophysiology, explain how to diagnose, and
describe the common management plans (lifestyle,
medications, other therapeutic modalities,
monitoring) per evidence-based clinical guidelines.
4. List different point-of-care tests available and their
indications for use to guide adult patient care in an
ambulatory setting.
5. Describe standard dietary recommendations for an
adult or geriatric patient with a given condition.
6. Describe the mechanism of action,
contraindications to use, and drug interaction of
common medications used for acute and chronic
care of adults.
7. List the components of standard EKG
interpretation.
8. List the components of the CIWA protocol.
9. List indications, contraindications for common
procedures performed in the ambulatory and
inpatient setting.
10. List the underlying “normal” physiologic changes of
aging and how this affects presentation of disease.
11. Describe the altered metabolism and effects of
1.
19
PGY1: 1, 7, 8,
9
PGY2: 2, 3, 4,
6
PGY3: 5, 10,
11
drugs in the elderly.
Practice-Based Learning and
Improvement
Family Medicine residents
will learn to efficiently lead
and continuously improve the
multiple elements of care
delivery to adult and geriatric
patients.
Interpersonal and
Communication Skills
1. In both the inpatient and nursing home settings,
lead family meetings.
PGY3: 1
1. Describe the process of transitioning a geriatric
patient out of the hospital and into one of the
following places: home, skilled nursing facilities,
long term care, hospice/palliative care, assisted
PGY3: 1
Family Medicine residents
will learn to counsel their
patients with respect to
their acute or chronic
medical illnesses.
Family Medicine residents
will learn to counsel
patients and their families
in the hospital and nursing
home settings.
Family Medicine residents
will learn to communicate
effectively with faculty
physicians, consultants,
fellow residents, other
learners and other members
of the healthcare team.
Professionalism
Family Medicine residents
will demonstrate behaviors
consistent with the ethical
and responsible practice of
patient centered care.
Systems-Based Practice
Family Medicine residents
will learn to identify the
20
structure and operations of
health organizations and
systems and the effective
role of the family physician
within that system.
living facilities.
Appendix: Adult Medicine
Common Adult Medical Conditions/Complaints:
Cardiac: Chest pain, Congestive Heart Failure, Coronary Artery Disease, Hypertension, Hyperlipidemia, Atrial Fibrillation,
Palpitations
GI: GERD, Ulcers, Diverticulitis, Hepatitis, Steatosis, Cirrhosis, Inflammatory Bowel Disease, Abdominal pain Pancreatitis,
Irritable bowel syndrome, Rectal bleeding, Hernia, Hemorrhoids
Respiratory: Asthma, COPD, Sleep Apnea, Pulmonary Embolism, Cough, Pulmonary Fibrosis, Sarcoidosis, Shortness
of Breath, Pneumonia, Snoring
ENMT: hearing loss, tinnitus, sore throat, congestion, tooth pain, Dental Abscess, TMJ
Eye: eye pain, decreased vision, red eye, conjunctivitis, foreign body, periorbital cellulitis, iritis, myopia, presbyopia, cataracts
Musculoskeletal:
Fracture, Osteoarthritis, Spinal Stenosis, Pain in a joint, Chronic Back Pain, gait disorders
Rheumatological: Rheumatoid arthritis, SLE, Scleroderma, Fibromyalgia, Myalgias, Arthralgias
Psychiatric: Depression, Anxiety, Bipolar Disorder, Eating Disorders, substance use/abuse, dementia, delirium, insomnia,
narcolepsy
Gynecological: Well woman exam, Breast Mass, Abnormal Pap smear, Dysmenorrhea, Polycystic
Ovarian Syndrome, STD’s, Menopause, Vaginal Discharge, Contraception
Endocrine: Diabetes (Types I and II), Hypothyroidism, Hyperthyroidism, thyroid nodules, hypercalcemia, osteopenia,
osteoporosis
Neurologic: CVA/TIA, Neuropathy, Migraines, pseudotumor cerebri, Headache, dizziness, Cognitive decline, Parkinsons
Disease
Hematologic: Anemia, Pancytopenia, Coagulopathies, DVT, Anticoagulation Management
Genito-Urinary: Urinary tract infections (acute and recurrent), Interstitial Cystitis, Chronic Kidney Disease, Urinary
incontinence, Renal Failure (acute and chronic), dysuria, hematuria, urinary frequency, urinary hesitancy, BPH, sexual
dysfunction
Dermatology: Atopic dermatitis, psoriasis, abscesses, cellulitis, tinea, rash
Infectious: Tuberculosis, Viral Illnesses, Bacterial Illness, Scabies, HIV/AIDS
Preventive: Well Adult Male Exam, Well Woman Exam, Well Child Exam, Well Adolescent Exam
Constitutional: fever, fatigue, weight loss or gain, allergic reactions
Oncology: Colon cancer, breast cancer, prostate cancer, cervical cancer, lung cancer, pancreatic cancer, skin cancers
21
Topics to review specific to the inpatient service
•
Insulin use
•
Venous Thromboembolism
•
Vancomycin use
•
Alcohol and Drug Withdrawal
•
Symptomatic Treatment of CHF Exacerbation
•
Lumbar Puncture, Paracentesis,
Thoracentesis
•
Bridge Treatment for Anticoaculation
•
Chest Pain
•
Preoperative Assessment
•
Emergent/urgent HTN/crisis
•
Pain Management
•
COPD/Asthma
•
Antibiotic use
•
Blood transfusion guidelines
•
Management of Complications of Cirrhosis
•
HAP/CAP needing admission
•
Delirium and Dementia
•
GI Bleeding
Topics for review specific to geriatric patients in all settings (see also general topics above):
•
Cognitive Decline/Dementia
•
MMSE, Clox test
•
Evaluation of risk of falls
•
Functional status evaluation
•
Pressure sores
•
Dentures
•
Polypharmacy
•
Elder abuse & neglect
•
Nutrition
•
Activities of daily living/Instrumental activities
of daily living
22
Women’s Health
The curriculum must include experiences in non-obstetric women’s health. In addition, the curriculum should have 1 month of
structured clinical experience in gynecological care.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
Patient Care
1. Given a female patient with a common
gynecological condition or complaint (see
Appendix):
PGY1: 1a
Family Medicine residents
will learn to appropriately
manage patients
presenting with a women’s
health condition or
complaint.
a. Perform a reproducible history
and physical exam
PGY2: 1b, 1c,
1d, 1e, 1f
b. Develop a differential diagnosis
c.
Create an evidence based evaluation
and management plan
d. Use standard guidelines to order and
interpret the results of diagnostic
studies (labs, Xrays, EKGs, etc.)
e. Perform procedures necessary to
evaluation or manage the
patient’s condition (see
Appendix).
f.
Medical Knowledge
Family Medicine residents
will learn about common
acute and chronic
conditions that affect their
female patients.
Identify presenting signs and symptoms
of domestic violence
1. List the components of an age-appropriate
well woman visit
2. For common women’s health acute complaints (see
Appendix), list the presenting symptoms & physical
exam findings, the common causes, and recite
the outpatient work up and management.
3. For common women’s health chronic conditions (see
Appendix), describe the pathophysiology, explain
how to diagnose, and describe the common
management plans (lifestyle, medications,other
therapeutic modalities, monitoring) per evidence
based clinical practice guidelines.
4. List different point-of-care tests available and their
indications for use to guide women’s healthcare in
an ambulatory setting
5. Describe standard dietary recommendations for
a female with a given condition.
6. Describe the mechanism of action,
contraindications to use, and drug-drug interaction
23
PGY1: 1, 7
PGY2: 2, 3, 4,
6, 9
PGY3: 5, 8
of common
medications used for women’s healthcare.
7. List indications, contraindications for
common women’s health procedures
performed in the ambulatory setting.
8. List the normal physiologic changes of aging
in females from pre-puberty through
menopause
9. Describe how female patients might present atypically
with coronary artery disease
Practice-Based Learning
and Improvement
Family Medicine residents
will learn to efficiently lead
and continuously improve
the multiple elements of
care delivery within the
practice of women’s
healthcare.
Interpersonal and
Communication Skills
Family Medicine
residents will learn to
counsel their female
patients with respect
to their healthcare
needs.
1. Provide patient-centered confidential counseling to
female patients when they present with symptoms
or physical exam findings consistent with possible
domestic violence.
Family Medicine
residents will learn to
communicate effectively
with faculty physicians,
consultants, fellow
residents, other learners
and other members of
the healthcare team.
Professionalism
24
PGY2: 1
Family Medicine residents
will demonstrate behaviors
consistent with the ethical
and responsible practice of
patient centered care.
Systems-Based Practice
Family Medicine residents
will learn to identify the
structure and operations of
health organizations and
systems and the effective
role of the family physician
within that system or the
field of gynecology.
1. Identify resources available in the community for
female patients and their families who
experience domestic violence.
25
PGY1: 1
Appendix: Women’s Health Conditions
Common Conditions/Complaints:
•
Well woman exam
•
Amenorrhea (primary and secondary)
•
Vaginal discharge
•
Dysfunctional Uterine Bleeding
•
Vaginal itching
•
Cervical polyp
•
Pelvic Pain
•
Vaginitis: BV, candida
•
Dysmenorrhea
•
Hirsuitism
•
Menopause
•
Polycystic Ovary Syndrome
•
Hot flashes
•
Domestic violence
•
Irregular bleeding
•
Osteoporosis
•
Urinary incontinence
•
Infertility
•
Contraception
•
Galactorrhea
•
Breast mass
•
Breast cancer
•
Fibroadenoma
•
Fibrocystic Breast Disease
•
Pelvic floor dysfunction & bladder, uterine,
rectal prolapse
•
Post-exposure prophylaxis for STDs/HIV &
pregnancy
•
Mood disorders: depression, anxiety,
premenstrual mood disorder
•
STD: gonorrhea, chlamydia, trichamoniasis,
syphilis, HIV, herpes, genital warts
Procedures:
•
•
•
•
•
•
•
•
•
•
Pap smear
Wet prep & KOH slides
Colposcopy, cervical biopsy, endocervical curettage
Cryotherapy of cervical lesions
Endometrial biopsy
Treatment of genital warts
STD testing
Cervical polyp removal
Preconception counseling
Contraceptive counseling
26
Children’s Health
The curriculum must include 4 months of structured clinical rotations in the care of infants, children and adolescents.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
Patient Care
Patient Care
PGY1: 1a, 1b,
Family Medicine
residents will learn to
appropriately manage
patients presenting for
well child care
1. Given an infant, child or adolescent presenting for a
wellness visit:
1c, 1d, 1h, 1i;
2a, 2g; 3a, 3b,
a. Perform a complete and reproducible ageappropriate history including: Birth
3c; 4a, 4b, 4f,
History when appropriate, Immunization
4g; 5a, 5b, 5c,
History, and Nutritional History
5d, 5e, 5f, 5g
b. Perform a complete and reproducible ageappropriate physical exam including correct
evaluation of vital signs and use of blood
pressure charts.
PGY2: 1e, 1f,
c.
Perform proper evaluation of growth and
development including: correct plotting and
interpretation of growth charts, age-
appropriate developmental milestones,
Tanner staging
e. Recognize signs of physical and/or sexual abuse
and follow the proper steps of
management and reporting
Determine age-appropriate immunizations
and manage catch-up immunization
schedules when necessary.
g. Follow recommended age-appropriate screening
evaluations.
h. Perform proper interpretation of hearing and
vision screening tests.
i.
Provide age appropriate anticipatory
guidance
j.
2d, 2e, 2f, 2h,
2i, 2j; 3d, 3e,
3f; 4c, 4d, 4e,
4h, 4i, 4j, 4k
d. Demonstrate the ability to do an adolescent
“HEADS” assessment
f.
1g, 1j; 2b, 2c,
Manage any abnormal findings in the history
and/or the physical exam as outlined by the
evaluation of an acute complaint
2. Given a child with an acute condition or complaint
(see Appendix):
27
a. Obtain appropriate history, including determining
the reliability of the historian
b. Perform a reproducible problem focused physical
exam
c.
Develop a differential diagnosis
d. Create an evidence based evaluation and
management plan
Family Medicine
residents will learn to
appropriately manage
children and
adolescents
presenting with acute
complaints
e. Use standard guidelines to order and interpret
the results of diagnostic studies
(labs, Xrays, EKGs, etc…)
f.
Perform bladder catheterization when
indicated
g. Accurately calculate pediatric medicine dosing.
h. Recognize signs and symptoms of
possible abuse or neglect and manage accordingly
i.
j.
Demonstrate appropriate use and
interpretation of pneumatic otoscopy and
tympanograms.
Demonstrate accurate interpretation of
questionnaires for parents and teachers to
assess for ADHD
3. Given a child or adolescent with a chronic condition
(see Appendix):
a. Obtain appropriate history, including
determining the reliability of the historian
b. Perform a reproducible physical exam c.
Identify an appropriate clinical practice
guideline, if available
d. Create an evidence based evaluation and
management plan
Family Medicine residents
will learn to appropriately
manage children and
adolescents with common
chronic childhood
diseases
e. Use standard guidelines to order and
interpret the results of diagnostic studies
(labs, Xrays, EKGs, etc.)
f.
Address the special healthcare needs of
children with disabilities
4. Given a child or adolescent needing hospitalization a.
Perform a reproducible, comprehensive history,
including birth history when appropriate and growth
and developmental history.
28
b. Perform a reproducible, comprehensive
physical exam.
c.
Develop a differential diagnosis
d. Create an evidence based evaluation and
management plan
e. Use standard guidelines to order and
interpret the results of diagnostic studies
(labs, Xrays, EKGs, etc…)
f.
Family Medicine residents
will learn to appropriately
manage children and
adolescents hospitalized
for common childhood
illnesses.
Write a complete set of admission orders.
g. Calculate age appropriate dosing of
medications and/or replacement and
maintenance fluids.
h. Determine level of care needed and
arrange proper transfers and
consultations indicated in a timely
manner
i.
Identify appropriate procedures for
evaluate and manage the patient
j.
Determine criteria for discharge
k.
Arrange and coordinate discharge,
including appropriate follow up
5. Given a newborn in the nursery, ambulatory, or
inpatient setting
a. Perform a reproducible, comprehensive
birth history
b. Perform and score a complete Ballard
exam just after birth
c.
Perform a reproducible, comprehensive
newborn physical exam
d. Identify and manage common newborn
conditions according to clinical practice
guidelines
e. Identify newborns at risk for sepsis and
perform the proper evaluation and
management
f.
Provide appropriate anticipatory guidance
to parents prior to discharge from hospital
or clinic
g. Arrange and coordinate discharge,
including appropriate follow up
29
Family
Medicine
residents will learn to
appropriately
manage
newborns.
Medical Knowledge
Medical Knowledge
PGY1: 1, 4
Family Medicine
residents will learn
about the healthcare
of newborns, children,
and adolescents.
1. List the components of an wellness visit for newborns,
children, and adolescents.
PGY2: 2, 3, 5,
2. For common pediatric ambulatory chief complaints
(see Appendix), list the common causes and recite
the outpatient work up.
3. For common pediatric ambulatory chronic conditions
(see Appendix)*, describe the common management
plans per evidence based clinical practice
guidelines.
4. List different point-of-care tests available and their
indications for use to guide pediatric patient care in
an
ambulatory setting.
5. Describe standard dietary recommendations for
a pediatric patient with a given condition.
6. Given a specific pediatric chronic disease, list possible
associated nutritional deficiencies and describe the
evaluation and management of them.
Practice-Based Learning
and
Improvement
Family Medicine
residents will learn to
efficiently lead and
continuously improve
the multiple elements
of care delivery within
the practice of
children’s healthcare.
30
6
Interpersonal and
Communication Skills
1. Demonstrate the ability to adhere to
routine confidentiality policies regarding
minors.
PGY2: 1
Family Medicine
residents will learn to
counsel their patients
and/or parents of their
patients with respect
to their childhood
healthcare needs.
Family Medicine
residents will learn to
communicate effectively
with faculty physicians,
consultants, fellow
residents, other learners
and other members of
the healthcare team.
Professionalism
Family Medicine
residents will
demonstrate
behaviors consistent
with the ethical and
responsible practice
of patient centered
care.
Systems-Based Practice
Family Medicine
residents will learn to
identify the structure and
operations of health
organizations and
systems and the effective
role of the family
physician within the
practice of caring for
newborns, children and
adolescents
1. Demonstrate knowledge of and practice routine CPS
reporting guidelines
2. Demonstrate knowledge and practice of adhering
principles of minor emancipation
31
PGY2: 1, 2
Appendix: Children’s Health Curriculum
Common complaints/conditions:
Cardiac: Chest pain, murmur, Palpitations, Hypertension, Congenital Heart Disease
GI: GERD, Abdominal pain (acute & chronic), Colic, Irritable Bowel Syndrome, Rectal bleeding, Hernia,
Vomiting, Diarrhea, Dehydration, Constipation, Neonatal Jaundice
Respiratory: Asthma, Cough, Cystic Fibrosis, Pneumonia, TTN
ENT: Hearing Loss, Tinnitus, Sore Throat, Congestion, Viral URI, Otitis Media, Strep Pharyngitis, Epiglottis, RSV Bronchiolitis,
Croup, Epistaxis, Ear Pain
Eye: Eye Pain, Decreased Vision, Red Eye, Conjunctivitis, Foreign Body, Periorbital Cellulitis, Myopia
Musculoskeletal: Fracture, Sprains, Scoliosis, Pain in a joint, Growth Plate Injuries, Osteomyelitis, Developmental
Dysplasia of the Hip
Rheumatological: Juvenile Rheumatoid arthritis, Myalgias, Arthralgias
Psychiatric: Depression, Anxiety, Bipolar Disorder, Eating Disorders, Substance Use/Abuse, ADHD, Autism
Gynecological: Well woman exam, Breast Mass, Abnormal Pap smear, Dysmenorrhea, Polycystic Ovarian
Syndrome, STDs, Vaginal Discharge, Contraception
Endocrine: Diabetes (Types I and II), Congential Adrenal Hyperplasia, Premature Puberty, Tanner Stages
Neurologic: Migraines, Headache, dizziness, Epilepsy, Concussion
Hematologic/Lymphatic: Anemia, Pancytopenia, Hemoglobinopathies, Lymphadenopathy
Genito-Urinary: Urinary tract infections (acute and recurrent), dysuria, hematuria, urinary frequency, phimosis,
paraphimosis
Dermatology: Atopic dermatitis, abscesses, cellulitis, tinea, rash, Insect Bites
Infectious: Tuberculosis, Viral Illnesses, Bacterial Illness, Scabies, Neonatal Sepsis, Kawasaki Disease, Meningitis
Preventive: Well Child Exam, Well Adolescent Exam
Constitutional/General: fever, fatigue, weight loss or gain, Failure to Thrive, Allergic Reactions, Obesity, Developmental
Delay, Newborn Screening, Poisoning, Child Abuse
Oncology: Retinoblastoma, Wilms Tumor, Neuroblastoma, Cervical Cancer, Primary Brain Cancer
32
Maternity
The curriculum must include at least 2 months of experience in maternity care. Residents must complete 40 deliveries,
including at least 10 continuity patient deliveries.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
Patient Care
1. Given a woman of childbearing age:
PGY1: 1b, 2a,
Family Medicine
residents will learn to
care for women of
childbearing age
contemplating
pregnancy.
Family Medicine residents
will learn to appropriately
diagnose, evaluate and
manage pregnant and
postpartum woman.
a. Provide evidence-based preconception
counseling.
b. Accurately diagnose pregnancy.
c.
Provide patient-centered options counseling.
2. Given a pregnant patient presenting for prenatal care:
a. Obtain a reproducible history
b. Establish gestational age.
c.
Provide comprehensive prenatal care
according to established guidelines.
3. Given a pregnant patient presenting with an acute
complaint or condition:
a. Perform a reproducible history and physical
exam.
b. Develop a differential diagnosis.
c.
Create an evidence-based evaluation and
management plan.
d. Use standard guidelines to order and interpret
the results of diagnostic studies (labs, X-rays,
EKGs,
etc.)
e. Perform appropriate procedures.
4. Given a pregnant patient presenting for labor
evaluation:
a. Accurately diagnose labor.
b. Accurately evaluate for rupture of
membranes.
c.
Manage labor according to evidence-based
guidelines.
d. Manage labor induction and augmentation.
33
2b,3a, 3b, 3d,
4a, 4b, 5a, 5b,
5c, 5d
PGY2: 1a, 1c,
2c, 3c, 3e, 4c,
4f, 4g
PGY3: 4d
e. Manage complications associated with labor:
fetal distress, labor dystocia, shoulder
dystocia, hemorrhage, fever.
f.
Manage the vaginal delivery
g. Perform appropriate procedures
5. Given a postpartum patient:
a. Provide routine postpartum anticipatory
guidance.
b. Screen for postpartum depression.
c. Manage postpartum
complications.
d. Complete an evidence-based postpartum
visit.
*See Maternity care procedures list.
Medical Knowledge
Family Medicine residents
will learn about
preconception care,
pregnancy, and
postpartum.
1. List the components of preconception counseling.
PGY1: 1, 2, 3,
2. List the methods to diagnose pregnancy.
5, 6, 8, 12, 17
3. List the methods of establishing gestational age and
their appropriate use.
4. Discuss the established components of routine
prenatal care at each gestational age.
PGY2: 4, 7, 9,
5. Identify conditions that make a pregnancy “high risk”.
10, 11, 13,
6. List indications for referral to a genetic counselor.
7. Define active labor, describe the use of the labor
curve, and discuss the expected durations of each
labor stage for nulliparous vs. multiparous patients
with or without epidural anesthesia.
8. List the methods for determining rupture
of membranes.
9. Define labor dystocia.
10. List indications and contraindications for labor
34
14,15, 16
induction.
11. List indications for instrument assisted vaginal delivery
or C-section.
12. Interpret FHR monitoring strips.
13. List the diagnostic criteria for the common
complications of pregnancy*.
14. List indications, contraindications and complications of
labor analgesia.
15. Describe the differences of various perineal
lacerations, list the complications of each and
describe the mechanism of repair for each.
16. Describe the steps of a C-Section.
17. List common post-partum conditions or complications:
pain, breastfeeding problems, depression, DVT/PE,
infection.
Practice-Based Learning
and
Improvement
Family Medicine residents
will learn to efficiently lead
and continuously improve
the multiple elements of
care delivery within the
care of pregnant women
Interpersonal and
Communication Skills
1. Provide patient-centered counseling on options for
unplanned pregnancy, pregnancy loss, and fetal
anomalies
Family Medicine
residents will learn to
counsel their patients
and family with respect
to their pregnancy and
care of their newborn.
Family Medicine
residents will learn to
communicate effectively
with faculty physicians,
35
PGY2: 1
consultants, fellow
residents, other learners
and other members of
the healthcare team.
Professionalism
Family Medicine residents
will demonstrate behaviors
consistent with the ethical
and responsible practice of
patient centered care and
operations of health
organizations and systems
and the effective role of the
family physician within the
settings that care for
pregnant women.
Systems-Based Practice
Family Medicine residents
will learn to identify the
structure
36
Appendix: Maternity Care
Common complications of pregnancy, labor, and the immediate postpartum period:
•
Gestational Diabetes
•
Chorioamnionitis
•
Gestational Hypertension
•
Prolapse of the umbilical cord
•
Preeclampsia
•
Shoulder dystocia
•
Eclampsia
•
Fetal distress
•
Placenta Previa
•
Labor anesthesia complications
•
PUPP
•
Retained placenta
•
Pyelonephritis
•
Postpartum hemorrhage
•
STDs
•
Endometritis
•
Cholestasis of pregnancy
•
Postpartum depression
•
Thromboembolic disorders
•
Lactation difficulties
•
PROM, pre-PROM
•
Mastitis
•
Placental abrubtion
•
Hemorrhoids
•
Amniotomy
Procedures
• Sterile Speculum Exam
•
Placement of Fetal Scalp Electrode
•
Interpretation of FHR monitor
•
First assist for Cesarean section
•
Slides for ferning, KOH, wet prep
•
Ultrasound to determine presentation and
fetal lie
Placement for an Intrauterine Pressure
Catheter
•
Ultrasound to determine Amniotic Fluid Index
•
Operative vaginal delivery using vacuum
•
37
Surgery
The curriculum must include 2 months of General Surgery experience, including ambulatory care, inpatient care, operating room
experience, and post-operative care experience.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
Patient Care
1. Given a patient with a common surgical condition (see
appendix)
PGY1: 1a, 1b,
Family Medicine
residents will learn to
appropriately manage
patients presenting with
common surgical
complaints.
a. Perform a reproducible history and physical
exam
b. Develop a differential diagnosis
c.
Create an evidence based evaluation and
management plan
1e; 2
PGY2: 1c, 1d,
1f; 3, 4, 5
d. Use standard guidelines to order and interpret
the results of diagnostic studies (labs, Xrays,
EKGs, etc…)
e. Use standard guidelines to perform a
preoperative evaluation
f.
Manage the postoperative period, including
proper identification and management of
immediate postoperative complications
and management of pain.
2. Given a patient who presents for a minor surgical
procedure, obtain informed consent.
3. Demonstrate the ability to suture and close wounds.
4. Demonstrate the ability to adhere to the surgical
principles of asepsis and tissue handling.
5. Demonstrate the ability to perform minor surgical
procedures (see appendix)
Medical Knowledge
Family Medicine
residents will learn
1. For the conditions listed below, list the common
causes and recite the ambulatory or emergent work
up:
38
PYG1: 1, 3, 5
about indications for
surgery, preoperative
assessments, and
postoperative
complications of
common surgical
conditions.
PGY2: 2, 4
a. Abdominal
pain b. Breast
Mass
c.
Tumor
d. Anal-rectal
disorders e. Hernia
f. Vascular surgical
conditions g. Eye pain
h. Hematuria
2. Describe the principles of the care of wounds in
different stages of healing.
3. List the components of a preoperative assessment.
4. List common complications of major surgery.
5. List the components of obtaining informed consent.
Practice-Based Learning
and Improvement
Family Medicine
residents will learn to
efficiently lead and
continuously improve
the multiple elements of
care delivery within the
practice of surgery
Interpersonal and
Communication Skills
Family Medicine
residents will learn
to counsel patients
with respect to their
surgical conditions.
39
Family Medicine
residents will learn to
communicate
effectively with faculty
physicians,
consultants, fellow
residents, other
learners and other
members of the
healthcare team.
Professionalism
Family Medicine
residents will
demonstrate behaviors
consistent with the
ethical and responsible
practice of patient
centered care.
Systems-Based Practice
Family Medicine
residents will learn to
identify the structure
and operations of
health organizations
and systems and the
effective role of the
family physician and
surgeon within that
system.
40
Appendix: Surgery
Minor Surgical Procedures:
•
•
•
•
•
•
•
•
•
Toenail excision
Infant circumcision
Laceration repair/Suturing techniques including: double layer, single layer, interrupted simple sutures, vertical mattress
sutures, and subcuticular sutures
Excision of lesion
I&D
Destruction of lesion/cryotherapy
Wound debridement/care
Vasectomy*
Colonoscopy*
*Optional with elective experience per resident interest
Surgical Conditions and Complaints:
•
•
•
•
•
Ophthalmology: red eye, acute visual disturbance, eye pain, foreign body in eye, diabetic retinopathy, glaucoma,
cataract
Otolaryngology: ear pain, decreased hearing, foreign body in ear/nose, snoring
Urology: hematuria, urinary incontinence, urinary stone, BPH, prostate cancer
General Surgery: abdominal pain, appendicitis, cholecystits, biliary colic, diverticulitis, colon cancer, hernias, breast
mass, vascular surgical conditions (carotid, aortic, peripheral)
Cardiothoracic: valve replacement, CABG
41
Musculoskeletal & Sports Medicine
The curriculum must include 2 months of musculoskeletal and orthopedic clinical experience, including a separately identified
sports medicine curriculum.
Goals for Graduation
Patient Care
Family Medicine residents
will learn to appropriately
manage adult and pediatric
patients presenting with of
musculoskeletal and sports
medicine problems.
Learning Objectives
Level at which
competence is
required
1. Given a patient with a common musculoskeletal
or sports medicine problem (see Appendix):
a. Perform a reproducible history and
physical exam.
b. Develop a differential diagnosis.
c.
Create an evidence-based management plan.
d. Use standard guidelines to order and interpret
the results of diagnostic studies (imaging
studies, joint aspirations)
PGY1: 1a, 1e;
2
PGY2: 1b, 1c,
1d; 3
e. Perform appropriate diagnostic and therapeutic
maneuvers.
2. Perform a standardized pre-participation
sports evaluation.
3. Given a patient with a sports injury, develop an
evidence-based rehabilitation plan for the patient,
including return to play recommendations.
Medical Knowledge
Family Medicine residents
will learn about
musculoskeletal and sports
medicine problems.
1. Given a patient with a musculoskeletal problem
or sports injury (see Appendix):
a. List the common causes.
b. Describe specific diagnostic maneuvers used
to diagnose the problem.
c.
Describe the anatomy and biomechanics of the
injury.
d. Describe the considerations of
musculoskeletal and sports-related
injuries in special populations
(children, developmentally disabled,
etc.)
e. Describe the physiology of the
rehabilitative process relevant to a
particular injury.
f.
Describe the management plan per
standard guidelines.
g. List indications for operative
management.
2. Given a patient with a sports injury or condition (see
Appendix):
42
PGY1: 1a, 1b,
1c
PGY2: 1d, 1e,
1f, 1g; 2a, 2b,
2c; 3, 4,
a. List conditions which would limit the patients’
ability to participate in sports.
b. Describe the nutrition and fluid management
requirements of athletes.
c.
Describe the specific modifications to a
sports evaluation for a patient with
developmental disabilities.
3. Describe how eating disorders, pressure to perform,
pressure from parents and coaches and steroid
abuse affect athletes.
4. Describe how medical conditions might affect
patients’ ability to exercise and play sports
Practice-Based Learning and
Improvement
Family Medicine residents
will learn to efficiently lead
and continuously improve the
multiple elements of care
delivery within the practice of
musculoskeletal and sports
medicine
Interpersonal and
Communication Skills
Family Medicine
residents will learn to
counsel their patients
with respect to
orthopedic, sports
medicine and
musculoskeletal
problems.
Family Medicine residents
will learn to communicate
effectively with faculty
physicians, consultants,
fellow residents, other
learners and other
members of the healthcare
43
team.
Professionalism
Family Medicine
residents will
demonstrate behaviors
consistent with the
ethical and responsible
practice of patient
centered care. Apply safe
return-to-play decision
making in clinical
practice regardless of
pressure from the athlete
or the coaches.
Systems-Based Practice
Family Medicine
residents will learn to
identify the structure and
operations of health
organizations and
systems and the
effective role of the
family physician within
that system.
1. Use standard orthopedic and radiographic language
to communicate an injury and reason for consult to an
orthopedic physician.
44
PGY2: 1
Appendix: Musculoskeletal & Sports Medicine Curriculum:
Common conditions/complaints:
Neck pain, Back pain, Foot pain, Joint pain, Joint swelling, Decreased range
of motion, Fracture, Growth Plate Injury, Sprain, Ligament tear, Contusion,
Tendonitis, Tenosynovitis, Bursitis, Carpal Tunnel Syndrome, Complex
Regional Pain Syndrome, Fibromyalgia, Lyme Disease, Arthritis (osteo,
rheumatoid, septic, psoriatic, JRA) ,
Scoliosis, Dupuytren’s contracture, Morton’s Neuroma, Ganglion Cyst,
Compartment Syndrome, Concussion, Shoulder conditions (impingement,
rotator cuff, etc), Dislocated joint, Nursemaid’s Elbow,
Trigger finger, Shin Splints, Baker’s cyst, Patellofemoral syndrome,
Bunion, Plantar Fasciitis
Procedures
•
•
•
Casting and Splintingfingers, wrist, forearm,
ankles, foot, hand
Shoulder sling
Joint injection and aspiration
o Knee
o Shoulder
o carpal tunnel
o ganglion cyst
o plantar fascia
Diagnostic maneuvers
Range of motion testing and
stability testing for joints
•
•
•
•
•
•
Back exam: Straight leg
raise test
Knee: anterior and
posterior drawer,
Lachman’s, medial and
lateral laxity, abduction
stress, MacMurray
Shoulder: Empty can
test, Drop arm test
Carpal Tunnel: Phalen’s
test, Tinel’s sign
Hip: Patrick’s test
Ankle: Drawer test,
inversion stress test,
Th
t t
45
Return to play decisions
• Fractures
• Sprains
• Post-operative
• Concussion
Rehabilitation
•
•
•
•
•
Use of canes, crutches,
walkers, diabetic
shoes
Sports foot wear
Shoulder exercises
for impingement
Back exercises for
mechanical low back
pain
Foot exercises for
plantar fasciitis
Critical & Emergency Care
The curriculum must include 200 clinical hours of Emergency Medicine training and the opportunity for residents to participate
in the substantial portion of care for at least 15 critically ill hospitalized patients.
Goals for Graduation
Patient Care
Learning Objectives
Level at which
competence is
required
1. Given a critically ill patient, or a patient presenting to
the emergency department:
Family Medicine
residents will learn to
appropriately manage
patients presenting with
or developing critical
illness.
a. Obtain a reproducible history and
physical exam.
b. Utilize standard emergency protocols
to stabilize patient.
c.
PGY1: 1a, 1b,
1c, 1e; 2
PGY2: 1d, 1f;
3
Develop a differential diagnosis.
d. Create an evidence-based evaluation
and management plan.
Family Medicine residents
will appropriately evaluate
and manage both adult and
pediatric patients
presenting to the
Emergency Department.
e. Use standard guidelines to order and
interpret the results of diagnostic
studies (labs, X-rays, EKGs)
f.
Perform appropriate procedures.*
g. Perform ACLS.
h. Perform ATLS.
Family Medicine residents
will recognize critically
patients and initiate life
support protocols
Medical Knowledge
Family Medicine residents
will learn about the care of
critically ill patients.
*reference Critical Care and Emergency Procedures list
1. Given a patient with a critical condition or
issue*:
a. List the common causes
.
PGY1: 1a, 1b;
2, 6, 9
b. Recite initial stabilization plan.
PGY2: 1c, 1d,
c.
3, 4, 5, 7, 8, 10
Describe the common management
plan per evidence-based guidelines.
d. List indications for admission to
or transfer to an intensive care
setting.
46
2. List the components of a standard EKG interpretation.
Family Medicine residents
will learn the differential
diagnosis and initial
management for the
conditions seen frequently in
the Emergency Department.
3. List the indications for common
procedures*performed on critically ill patients.
4. List the elements of the Glasgow Coma Scale.
5. List the indicators followed in the CIWA
protocol.
6. Accurately calculate pediatric medication dosing
by weight.
7. Understand the acute management of pediatric
dehydration; order fluid and electrolyte
replacement
appropriately.
8. Describe the systematic method of cervical
spine radiologic interpretation in the trauma
setting.
9. Apply ACLS guidelines to the management of
patients in cardiac arrest and with life threatening
arrhythmias
or acute coronary syndromes
10. Apply ATLS guidelines to patients presenting
with traumatic injuries.
*reference Critical Conditions, Issues & Procedures List
Practice-Based Learning and
Improvement
Family Medicine residents
will learn to be an efficient
team member and to
continuously improve the
multiple elements of care
delivery for critically ill and
emergency department
patients
Interpersonal and
Communication Skills
Family Medicine residents
will learn to counsel their
patients and their families
with respect to critical
illness, injuries and
1. Use patient centered communication skills to explain
to patients their conditions and management
options, including breaking bad news and DNR/DNI
decisions.
2. Lead a family meeting about a critically ill patient.
47
PGY2: 1,2
management plans.
Family Medicine residents
will learn to communicate
effectively with faculty
physicians, consultants,
fellow residents, other
learners and other members
of the healthcare team.
Professionalism
Family Medicine
residents will
demonstrate behaviors
consistent with the
ethical and responsible
practice of patient
centered care.
Systems-Based Practice
1. Identify the system for urgent evaluation of
sexual assault victims within your institution.
PGY1: 1
Family Medicine residents
will learn to identify the
structure and operations
of health organizations
and systems and the
effective role of the family
physician within a setting
that cares for critically ill
patients.
References: AAFP Reprints: #291: Care of the Critically Ill Adult, #285: Urgent and Emergent Care, #260
Care of Infants and Children.
48
Appendix: Critical & Emergency Care
Critical Care and Emergent Conditions List for Adult and Pediatric Patients
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Basic homeostasis: circulation, respiration, dehydration
Renal disease and metabolic disorders: renal failure, oliguria, acid-base, electrolyte abnormalities
Cardiovascular conditions: acute coronary syndromes, cardiopulmonary arrest, dysrhythmias, hypertensive
urgency and emergency, heart failure, cardiac pulmonary edema, syncope
Endocrine: DKA, thyroid storm, hyperosmolar nonketotic acidosis, adrenal dysfunctions, other endocrine
emergencies
Hematologic: bleeding disorders, coagulopathies, transfusion therapy and reactions, venous thromboembolic
disease
Gastrointestinal: acute abdomen, gastrointestinal bleeding, hepatic failure, pancreatitis
Respiratory: respiratory failure, ARDS, pulmonary embolism, pneumonia, pulmonary hypertension, severe airflow
obstruction, severe asthma exacerbation, epiglottitis, croup, foreign body aspiration
Neurological: coma, mentation disorders, cerebral vascular accidents, meningitis, encephalitis, brain and spinal cord
trauma and disease, seizures, movement disorders, neurological emergencies, analgesia, sedation, intracranial
hemorrhage
Infectious disease: sepsis, antimicrobial therapy, immunocompromised patients, clostridium difficile and
pseudomembranous colitis, complications of pharyngitis
Multisystem: shock, hypothermia, hyperthermia, rhabdomyolysis, multisystem organ failure, overdose and poisonings,
alcohol and drug withdrawal, trauma, thermal injury
Preventative practices: alimentary, infection control, venous thromboembolism, decubitus ulcers, nutrition and
feedings
End of Life: withdrawing life support, organ donation and transplantation
Ocular emergencies
Musculoskeletal injuries: fractures and dislocations
Inflammatory disorders- kawasakis disease, henoch schonlein purpura, vasculitis
Other conditions- epistaxis, evaluation of sexual assault
Procedures
•
•
•
•
•
•
•
•
•
•
•
•
•
LP
Paracentesis
Thoracentesis
Central Line
Arterial Puncture
Arterial Line
Intubation
Ventilator management
External pacemaker placement
Electrical and chemical cardioversion
Laceration repair
Bladder catheterization and suprapubic aspiration
Vascular access including peripheral and central lines, Intraosseous access
49
Human Behavior & Mental Health
The curriculum must include opportunity for residents to acquire knowledge and skills in this area, accomplished primarily in the
ambulatory setting.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
Patient Care
1. Given a patient with a common mental
health complaint or condition (see
Appendix):
PGY1: 1a, 3
Family Medicine residents
will learn to appropriately
manage patients presenting
with mental health
conditions or complaints.
a. Perform a reproducible history
and physical exam.
PGY2: 1b, 1c,
1d; 2a, 2b; 4
b. Develop a differential diagnosis.
c.
Create an evidence-based evaluation
and management plan.
d. Use standard guidelines to order
and interpret the results of
diagnostic studies (labs, X-rays,
EKGs, etc.)
2. Given a patient with an acute or chronic
medical condition or major life stressor
(death of family member, disability, loss of
job or home, etc.)
a. Assess patient for emotional or
stress reaction.
b. Manage emotional or stress reactions.
3. Promote mental and emotional health by
counseling patients to maintain healthy lifestyle.
4. Create a genogram for a patient.
Medical
Knowledge
Family Medicine residents
will learn about mental
health
and
human
behavior
1. For common mental health acute complaints (see
Appendix), list the presenting symptoms and
physical exam findings, the common causes, and
recite the outpatient work up and management.
PGY1: 1, 2
PGY2: 3, 4
2. For common health chronic conditions (see
Appendix), describe the pathophysiology, list
the diagnostic criteria, and describe the
50
common management plans (lifestyle,
medications, other therapeutic modalities,
monitoring) per evidence- based clinical
practice guidelines.
3. Name major developmental milestones in
infants, children, adolescents, adults, seniors,
and families.
4. Describe the concepts of family systems/dynamics.
Practice-Based Learning and
Improvement
Family Medicine residents will
learn to efficiently lead and
continuously improve the
multiple elements of mental
and behavioral care delivery.
1. Identify “difficult patient encounters” and explore
the
doctor-patient dynamic internally, and with
colleagues and faculty to determine the best
resolution to the problem encounter.
Interpersonal and
Communication Skills
Family Medicine residents
will learn to counsel their
patients with respect to
their mental health needs.
Family Medicine residents will
51
PGY2: 1
learn to communicate
effectively with faculty
physicians,
consultants, fellow
residents, other learners
and other
members of the healthcare
team.
Professionalism
Family Medicine residents
will demonstrate behaviors
consistent with the ethical
and responsible practice of
patient centered care.
Systems-Based Practice
Family Medicine residents
will learn to identify the
structure and operations of
health organizations and
systems and the effective
role of the family physician
within the behavioral health
system.
1. Demonstrate knowledge of and practice routine CPS
& APS reporting guidelines
2. Demonstrate knowledge of and practice of
emergency detention procedures
References: AAFP Reprints, #270: Human Behavior & Mental Health
52
PGY2: 1, 2
Appendix: Human Behavior & Mental Health Curriculum
Common Conditions and Complaints:
Undifferentiated complaints that may indicate a behavioral or mental problems:
•
•
•
•
•
•
•
•
Fatigue
Multiple somatic complaints
Chronic headache
Chronic pain
Poor concentration
Chronic abdominal/pelvic pain
Change in weight or appetite
Pseudoseizures
Conditions and Diagnoses:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Depression
Bipolar Disorder
Schizophrenia
Schizoaffective disorder
Anxiety Disorders/ Panic attacks
Somatic disorder
Personality Disorders
Interpersonal Violence
Acute psychiatric conditions including suicidality
ADHD/ADD
Grief reactions or other life stressors
Drug seeking behaviors
Substance abuse disorders
Life transitions and coping mechanisms
53
Community and Occupational Medicine
The community medicine curriculum must include some experiential components as well as clinical experience in occupational
medicine.
Goals for Graduation
Learning Objectives
Level at
which
competence
is required
Patient Care
1. Demonstrate a willingness to advocate for a
health care system that is accessible and
affordable to all.
PGY1: 1, 3,
2. Collaborate with community organizations to
improve the health and well-being of patients and
their families.
PGY2: 2, 4b,
Family Medicine residents
will learn to recognize
factors associated with the
differential health status
among subpopulations,
including racial, geographic
or socioeconomic health
disparities and the role of
family physicians in
reducing such gaps.
Family Medicine residents will
learn to appropriately manage
patients presenting with
occupational health related
complaints or issues.
3. Demonstrate the ability to develop and participate
in culturally sensitive health promotion and
disease prevention activities and collaborative
projects with community groups.
4. Given a patient with a common occupational
health related condition:
a. Perform a reproducible history and
physical exam
b. Perform an occupation specific
history
c. Develop a differential diagnosis
d. Create an evidence based evaluation and
management plan
Medical Knowledge
e.
Use standard guidelines to order and
interpret the results of diagnostic studies
(labs, X-rays, EKGs, etc.)
f.
Develop an appropriate management plan
g.
Determine work modifications if necessary
1. Describe current public health issues and concerns
affecting local, state, and global societies.
Family Medicine residents
will learn about the issues
affecting healthcare of
communities and
resources available to
assist patients and their
2. List the environmental issues that influence
personal health, such as secondhand smoke,
sanitation, exposure to lead or other toxic
substances, housing safety, and occupational
54
4a, 4c
4d, 4e, 4f, 4g
families.
Family Medicine residents will
learn about Occupational
Medicine.
exposures.
3. List local, regional and national resources to
assist patients and their families in the
development and maintenance of healthy
lifestyles and disease prevention.
4.
Given a particular occupation, list potential
hazards, exposures or other job-related conditions
that could affect a patient’s health.
5. Describe how the Social Security Administration
determines if a patient qualifies for disability
benefits.
6. List local, state and federal resources available to
communities for disaster management and
planning.
7. Have a basic understanding of the primary
importance of safety in disaster responses including
personal protective equipment, decontamination
and site security.
8. Have an understanding of the principles of triage
and the ability to effectively perform triage in a
disaster setting.
9. Have an understanding of critical incident stress
management and the ability to apply it to debriefing in
the context of disaster response
Practice-Based Learning and
Improvement
Family Medicine residents will
learn to efficiently lead and
continuously improve the
multiple elements of care
delivery within the practice of
Occupational Medicine
55
Interpersonal and
Communication Skills
Family Medicine residents
will learn to communicate
effectively with faculty
physicians, consultants,
fellow residents, other
learners and other members
of the healthcare
team, including
community
organizations.
Family Medicine residents will
learn to counsel their patients
with respect to their
Occupational Health needs.
Professionalism
Family Medicine residents will
demonstrate behaviors
consistent with the ethical
and responsible practice of
patient centered care.
Systems-Based Practice
Family Medicine residents will
learn to identify the structure
and operations of health
organizations and systems
and the effective role of the
family physician within that
system.
1. Demonstrate skills to characterize an inner city
PGY2: 1, 2, 3
community, identify existing resources and areas
of health care need.
2. Identify various local, state, and federal agencies
and regulations that govern occupational health
and medicine.
3. Describe the reporting guidelines for communicable
diseases and how the health departments use this
information.
References: AAFP Reprints, #266 Occupational Medicine, #267 Health Promotion & Disease Prevention, #289B
Special Considerations in the Preparation of Family Practice Residents Interested in Inner City Practice, #290 Disaster
Medicine
56
Care of the Skin
The curriculum must expose residents to the diagnosis and management of common skin conditions.
Goals for Graduation
Patient Care
Learning Objectives
1. Given a patient with a common skin complaint/
Level at which
competence is
required
PGY1: 1a, 2
condition (see Appendix)
Family Medicine residents
will learn to appropriately
manage patients presenting
with a Skin condition or
complaint.
a. Perform a reproducible history and
physical exam
PGY-2: 1b, c, 3
b. Develop a differential diagnosis
c.
Create an evidence based evaluation and
management plan
2. Perform a preventive skin exam.
3. Perform common skin procedures.
Medical
Knowledge
Family Medicine residents will
learn about the diagnosis and
management of common skin
conditions *
1. Given a patient with a common skin condition or
complaint:
a. Classify the condition or list a differential
diagnosis for the complaint.
b. Describe the common management plan
per standard guidelines.
2. List indications and contraindications for
common skin procedures (see Appendix).
3. Describe various topical steroid
strengths and vehicles and the
appropriate use of each.
4. Recite the most common dermatologic
emergencies.
Practice-Based Learning and
Improvement
Family Medicine residents will
learn to efficiently lead and
continuously improve the
57
PGY2: 1, 2, 3,
4
multiple elements of care
delivery within the practice of
primary care as it is related to
the care of skin conditions.
Interpersonal and
Communication Skills
1. Teach patients how to prevent common skin
conditions caused by excessive sun exposure.
Family Medicine residents
will learn to counsel their
patients with respect to
their skin conditions.
Family Medicine residents will
learn to communicate
effectively with faculty
physicians, consultants,
fellow residents, other
learners and other members
of the healthcare team.
Professionalism
Family Medicine residents will
demonstrate behaviors
consistent with the ethical and
responsible practice of patientcentered care.
Systems-Based Practice
Family Medicine residents will
learn to identify the structure
and operations of health
organizations and systems and
the effective role of the family
physician within that system
Resources: AAFP Reprint #271: Conditions of the Skin
58
PGY1: 1
Appendix: Care of the Skin
Common skin conditions:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Childhood Dermatology: Normal skin changes, Childhood hemangiomas, Pustular diseases of childhood, diaper rash
and perianal dermatitis, newborn rashes
Acneiform Disorders: Acne vulgaris, Rosacea, Pseudofollicultis and Acne Keolidalis Nuchae, Hidranitis Suppurativa
Bacterial infections: Impetigo, Folliculitis, Pitted keratolysis, Erythrasma, Cellulitis, Abscess, Necrotizing fasciitis,
scarlet fever
Viral Infections: Chickenpox, Herpes Zoster, measles, Fifth Disease, Roseola, Hand, foot and mouth disease, herpes
simplex, molluscum contagiosum, common wart, flat warts, genital warts,
o plantar wart
Fungal Infections: Mucocutaneous candidiasis, tinea capitis, tinea corporis, tinea cruris, tinea pedis, tinea
versicolor
Infestations: Lice, scabies, cutaneous larva migrans
Dermatitis/ Allergic: atopic dermatitis, contact dermatitis, hand eczema, self-inflicted dermatoses, urticaria and
angioedema
Papulosquamous Conditions: seborrheic dermatitis, psoriasis, pityriasis rosea, lichen planus, Reiter’s syndrome,
erythroderma
Benign Neoplasms: skin tag, seborrheic keratosis, sebaceous hyperplasia, dermatofibroma, pyogenic granuloma
Nevi: benign nevi, Congenital nevi, Epiderma nevus, and nevus sebaceous, dysplastic nevus
Precancer/ Early Cancer: actinic keratoses and Bowen’s disease, Keratoacanthomas, Lentigo maligna, cutaneous
horn
Skin Cancer: Basal cell carcinoma, Squamous cell carcinoma, Melanoma
Infiltrative Immunologic: Granuloma annulare, pyoderma gangrenosum, sarcoidosis, mycosis fungoides
Hypersensitivity Syndromes: erythema multiforme, Stevens-Johnson Syndrome, toxic epidermal necrolysis, erythema
nodosum, cutaneous vasculitis
Connective Tissue Disease: Lupus erythematosus, dermatomyosis, scleroderma and morphea
Bullous Disease: bullous pemphigoid, pemphigus
Hair and Nail Conditions: alopecia areata, traction hair loss and trichotillomania, Scarring alopecia, Normal Nail
variants, pigmented nail disorders, onychocryptosis, paronychia, psoriatic
o nails, subungual hematoma
Pigmentary and Light related conditions: melasma, vitiligo, photodermatitis, erythema Ab Igne
Vascular : venous lake, cherry angioma, angiokeratosis, angiosarcoma, hereditary hemorrhagic telangiectasis, port
wine stain, hereditary hangiomatosis
Other skin disorders: cutaneous drug reactions, keolids, genodermatoses, erythema annulare centrifugum,
pregnancy related conditions
Reference: The Color Atlas of Family Medicine. Richard P. Usatine et al. McGraw Hill company 2009
Common Skin Procedures:
•
•
•
•
•
•
•
•
•
Scraping and preparation of KOH slide
Wood’s lamp illumination of lesions
Skin biopsy including excisional, punch, and shave biopsies
Administration of Local Anesthesia
Steroid injection of lesions
Incision and Drainage
Electrodessication
Cryotherapy
Laceration repair/ Suturing techniques including: double layer, single layer, interrupted simple sutures, vertical
mattress sutures, and subcuticular sutures
59
Diagnostic Imaging and Nuclear Medicine
The curriculum must include structured opportunities to learn and apply the concepts of diagnostic imaging and nuclear
medicine.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
Patient Care
1. Given a patient with a medical or surgical
condition, a. Based on the history
and physical exam,
PGY1: 1a, b, c
Family Medicine residents will
learn to appropriately order
and interpret diagnostic
imaging studies.
Family Medicine residents will
learn to appropriately consult
interventional radiology or
nuclear medicine.
determine if the patient
requires an imaging study to
establish a diagnosis
PGY2: 1d, e
b. Use standard guidelines to order the
appropriate radiologic study.
(American College of Radiology
Appropriateness Criteria)
c.
Apply the radiologists interpretation
of the imaging study to the specific
patient
d. Interpret plain films of the chest,
abdomen and musculoskeletal
system in a systematic fashion.
e. If indicated, appropriately consult an
interventional radiologist for
diagnostic or therapeutic procedure.
Medical Knowledge
1. List the indications and contraindications for the
PGY1 1
imaging studies listed in the appendix*
Family Medicine residents
will learn the indications,
contraindications, and
interpretation of common
diagnostic imaging studies.
PGY2: 2, 3, 4
2. For each study listed in the appendix,
understand radiation exposure to the
patient
3. For each study listed in the appendix, explain
the usefulness and safety of the study in
pediatric and pregnant patients
4. List indications for common Interventional
Radiology Procedures: biopsy, vascular
interventions, therapeutic or palliative taps
Practice-Based Learning and
Improvement
Family Medicine residents will
60
learn to efficiently lead and
continuously improve the
multiple elements of care
delivery within the practice of
primary care by improving
their own knowledge of the
usefulness of radiologic
studies in the diagnosis and
management of disease.
Interpersonal and
Communication Skills
Family Medicine residents
will learn to counsel their
patients effectively
regarding the risks, benefits
and costs of various
radiologic studies.
Family Medicine residents
will learn to communicate
effectively with radiologists,
faculty, physicians,
consultants, fellow
residents, other learners and
other members of the
healthcare team
Professionalism
Family Medicine residents
will demonstrate behaviors
consistent with the ethical
and responsible practice of
patient centered care.
Systems-Based Practice
1. When ordering a radiologic study consider cost
of the study and side effects vs. benefits to the
patient.
Family Medicine residents will
learn to identify the structure
and operations of health
organizations and systems
and the effective role of the
family physician when
ordering and interpreting
radiologic studies.
61
PGY1: 1
Appendix: Diagnostic Imaging and Nuclear Medicine
Plain X-ray
•
•
•
•
•
•
•
•
CT Scan
Spine- cervical , thoracic, lumbar
Chest
Upper extremity
Lower extremity
Pelvis, Hips
Abdomen
Skull
Ribs
•
•
•
•
•
MRI/MRA
•
•
•
•
•
Ultrasound
•
•
•
•
•
•
•
Head
Abdomen/Pelvis
Musculoskeletal system
Chest
Angiography: chest, liver, heart
Abdomen
Pelvis, including transvaginal
Emergency Medicine FAST exam
Obstetrical studies
Thyroid
Doppler studies: venous; renal
Breast
Brain
Spine
Musculoskeletal system
Abdomen/Pelvis
Breast
Nuclear Medicine
•
•
•
•
•
Dexa Scan
Mammography
62
HIDA scan
V/Q scan
Bone scan
Myocardial perfusion studies
Thyroid & parathyroid
Practice Management
The curriculum must include 100 hours of practice management, leadership, and ethics training.
Goals for Graduation
Learning Objectives
Level at which
competence
is required
Patient Care
1. Define the term patient centered care.
PGY1: 1,2,3
Family Medicine
residents will learn
about the ideals of a
patient centered
medical home and
the team based
approaches to
preventive, acute and
chronic health care
delivery.
2. List the elements of the chronic care model.
PGY2: 4
3. Describe the team approach to patient centered
healthcare delivery.
PGY3: 5
4. Demonstrate the ability to apply information technology at
the point of care to integrate clinical practice guidelines,
documentation guidelines, and patient education.
5. Demonstrate the ability to advocate for a patient’s welfare
while balancing the business realities of practice
management.
Medical Knowledge
1. Describe or define the following concepts:
a. Practice Opportunities
Family Medicine
residents will acquire a
basic fund of knowledge
to be able to make
informed decisions
about their professional
future regarding practice
structure and medical
care delivery systems.
b. Practice Facilities
c.
Medical Records
d. Staff & Personnel Policies
e. Legal Issues
f.
Computer Utilization
g. Hospital Issues
h. Marketing
i.
Resources
j.
Professional Relations
k.
Healthcare Risk Contracting
l.
Quality Indicators & Reimbursement
m. Practice Based Improvement
n. Lifelong learning and improvement
2. Define the principles of medical ethics:
63
PGY3: 1, 2
a. Autonomy
b. Physician Duty
c.
Beneficence
d. Non-malfeasance
e. Informed Consent
f.
Patient Capacity & Competency
g. Justice
Practice-Based Learning
and
1. Demonstrate the ability to analyze past and current
clinical practice to understand the root causes of
Improvement
problems and to improve future care based on previous
experiences (quality improvement cycle).
Family Medicine
residents will learn to
efficiently lead and
continuously improve the
multiple elements of
care delivery within the
practice of Family
Medicine.
PGY2:
1,2,3,4,5
2. Demonstrate the ability to evaluate personal practice for
potential liability risks.
3. Describe methods to mitigate professional liability risk.
4. Actively participate in a team effort to improve a process or
component of health care delivery in the Family Health Center
or on a residency-run inpatient setting.
5. Demonstrate the ability to identify measures of health (health
indicators, determinants of health, health disparities).
Interpersonal and
Communication Skills
Family Medicine
residents will learn
to counsel their
patients with respect
to their medical
conditions.
1. Describe mechanisms to protect patient confidentiality when
using information technology to document or
communicate about patients.
2. Explain the importance of proper communications with
external regulatory bodies, such as licensing boards, JAHCO,
OSHA, etc.
3. Actively conduct a practice search, interviews, contract
negotiations and successfully enter practice.
Family Medicine
residents will learn to
4. Demonstrate the ability to lead a patient care team.
64
PGY1: 1
PGY3: 2,3, 4
communicate
effectively with faculty
physicians,
consultants, fellow
residents, other
learners and other
members of the
healthcare team.
Professionalism
Family Medicine
residents will
demonstrate behaviors
consistent with the
ethical and responsible
practice of patient
centered care.
Systems-Based Practice
Family Medicine
residents will learn to
identify the structure and
operations of health
organizations and
systems and the
effective role of the
family physician within
that system.
1. Describe potential ethical conflicts with
pharmaceutical industries, health insurance
companies, and other health industry providers.
2. Describe potential ethical conflicts in personal conduct with
patients, staff & colleagues.
3. Describe the composition of the institutional ethics committee
and demonstrate proper referral of challenging ethical issues.
65
PGY1: 2
PGY2: 1
PGY3: 3
Scholarly Activity
The curriculum should provide opportunity for and require assistants to learn about and participate in scholarly
activities.
Goals for Graduation
Learning Objectives
Level at which
competence is
required
Patient Care
1. Given a patient with a common condition or
complaint, residents will:
PGY 2: 1, 2
Family Medicine residents will
learn to appropriately search,
retrieve, understand, and apply
medical evidence in patient
care.
a. Develop an answerable clinical
question
b. Search, find and appraise both
primary and secondary
information sources to answer the
clinical question.
c.
Apply the information to the specific
patient
2. Incorporate justice, beneficence, informed
consent, and respect for persons and their
privacy into research protocols
Medical Knowledge
Family Medicine residents will
learn the basic principles of
research, including how
research is conducted,
evaluated, and applied to
patient care.
1. Describe the basic principles of clinical
research,
PGY2: 1, 2,3
including research bias, measurement,
sampling, design, predictors and
outcomes.
2. Demonstrate understanding of simple
statistics and clinical epidemiology.
3. Articulate the findings, limitations,
strengths and implications of a
research study.
4. Describe the basic principles of research ethics
Practice-Based Learning and
Improvement
Family Medicine residents will
learn to efficiently lead and
PGY2: 1
1. Participate in development, implementation
and
analysis of the bi-annual resident Scholarly
Project
66
continuously improve the
multiple elements of care
delivery by learning about and
participating in scholarly
projects.
Interpersonal and
Communication Skills
Family Medicine residents will
learn to communicate scholarly
findings effectively with faculty
physicians, consultants, fellow
residents, other learners and
other members of the
healthcare team.
Professionalism
Family Medicine residents will
demonstrate behaviors
consistent with the ethical and
responsible practice of patient
centered care.
Systems-Based Practice
Family Medicine residents will
learn to identify the structure
and operations of research
systems and the effective role of
the family physician within that
system
References: AAFP Reprints #280: Information Management and Scholarly Activity
67
Rotation Schedules for 2014-2015 Academic Year
R1-PGY1 (13—four week blocks)
IPS1
A
Fam
Med/
Gyn
CCU
MSK1
Prac
IPS1
B
Mgmt
UHS
UHS
UHS
UHS
UHS/
CSR
UHS/
PVt
UHS
VA/
UHS
UHS
UHS
Elective
Amb
Peds
UHS
OB
ER
IPS1C
Newborn
Nursery
AmbPed
Backup
Elective
UHS
VA/
UHS
UHS
UHS
UHS
UHS
UHS
ERVA
OB
BehSci
Prac
Mgmt
VA/
UHS
UHS
UHS
UHS
R3-PGY3 (12—four week blocks)
IPS3
Inpt
Surg
Physician
R2-PGY2 (13—four week blocks)
Prac
Mgmt/
Outpt
Night
IPS2
MSK2
Surg
Hospital
Physician
UHS
Fam
Med/
Night
Hospital
EEU
Night
Hospital
Physician/
Prac
Mgmt
UHS/
VA
UHS
Geri
IPS
UHS
Elective
Mat
Sr
UHS
Geri
IPS
Amb
Pro
Inpt
Pedi
Comm
Med
UHS
UHS
UHS
UHS/
Pvt
Cards
Fam
Med
3
UHS/
VA
UHS
Elective
Elective
UHS=University Hospital or Health System; CSR=Christus Santa Rosa Hospital; VA=Audie Murphy Veterans Hospital
NOTE:
Longitudinal Curriculum: Throughout all three years of training, all residents spend an average of three to four half
days in continuity experiences. The majority of these continuity experiences are the family medicine clinics in the
Family Health Center (FHC).
Because scheduling 38 residents is a complex process, residents are required to verify that their schedule is
correct when they receive email notification that their schedule is finalized for a future block rotation. The reason
for this review is to identify errors or misunderstandings in advance. The goal is to eliminate problems that would
inconvenience patients or detract from educational experiences for you and your colleagues. In particular,
residents should check the following details, referencing the At-A-Glance for each particular rotation:
 Vacation, sick leave, and/or CME days are accounted for and there are no clinical activities
scheduled at that time
 There are no unscheduled sessions for a time the resident should be in a clinical setting
 The schedule accounts for any post-call status from the rotation prior to the new block
 Nursing home visits are scheduled appropriately
 Special meetings, such as Chiefs Meetings, GMEC meetings, etc., are correctly represented
 There are no potential duty hour violations on the schedule
68
RESIDENT EVALUATION & ADVISING
Evaluation
The overall evaluation of residents is the responsibility of the Program Director and the Clinical Competency
Committee. Residents are evaluated with written evaluations by faculty at the conclusion of each block rotation
and periodically by those faculty members with whom they work in the Family Health Center (FHC). In cases in which
there are multiple attendings, each attending is asked to complete an evaluation form. In the FHC, evaluations are
competency-based.
The Clinical Competency Committee evaluates each residency year group on a specific schedule. Residents are
evaluated using the Family Medicine Milestones. This evaluation will occur at least twice per year and will include a
self-evaluation by the resident. The resident will meet with the Program Director, the Associate Program Director, or
his or her advisor to discuss the evaluation. A formal report from the Clinical Competency Committee regarding a
resident’s overall progress is emailed to the resident and to his or her faculty advisor. Each resident is required to
review and electronically sign all evaluations through New Innovations. Paper copies of all evaluations are retained
in the resident’s evaluation folder and are always available for review by the resident.
Advising
Each resident is assigned a faculty advisor. Formal meetings between resident and advisor are required four times
per year. These meetings are conducted according to a set of guidelines listing the minimum areas of discussion.
At these meetings, the resident’s evaluation folder is reviewed—including all rotation evaluations, FHC evaluations,
in-training exam scores, procedure documentation, conference attendance, and progress of scholarly and quality
improvement projects, as well as other issues important to the individual resident’s progress in the program.
Written documentation of resident-advisor meetings is submitted to the residency office and retained in the
resident’s evaluation folder.
In-Training Exam
An important part of the evaluation of all residents is the In-Training Examination (ITE). This is required of all
residents and is administered in October annually. The results are utilized both individually for self-assessment and
in aggregate for the program. Residents are given a copy of their own scores and are required to discuss them with
their advisor. From this meeting, a plan should be developed to address any deficiencies noted. Residents
performing below the 20th percentile for their year are required to develop a formal study program with their
advisors and report on their progress to the Program Director at regular intervals. In the aggregate, the program
uses the ITE scores to assess the effects of curricular changes on the performance of our residents in those
particular content areas.
Promotion
Residents must be in good standing to be promoted to the next academic year. No resident on probation will be
promoted. Residents on probation on July 1st will be delayed in their progress through the program.
Residents must meet the Family Medicine Review Committee requirements for promotion from one year to the next.
In order to be promoted from the second year to the third, residents must have passed USMLE Step 3 prior to
March 1 of the PGY2 year, and those who are eligible must hold a Texas medical license. The residency faculty
meet once each year in early Spring to review all PGY1 and PGY2 residents’ overall progress toward promotion.
69
Resident Discipline: Due Process, Remediation, & Probation
The Residency Program Director may bring any resident up for special discussion at the Clinical Competency
Committee meeting. This will most often occur when adverse evaluations or other credible reports about the
resident have been received. If possible, the resident’s faculty advisor will be notified and invited to participate in
the meeting. If other faculty members have pertinent information related to the resident (e.g., were supervising
attendings on rotations or in clinic where problematic performance occurred), they too may be invited. Only the
Program Director has the authority to institute discipline measures within the program.
After discussion, the committee may choose to take one of the following actions:
1. No further action: The resident will be followed as all other residents. The resident need not be informed of
this action.
2. Monthly Review: The Residency Clinical Competency Committee will review the resident’s record at each
monthly meeting. This may occur based on an educational concern by any faculty member, or monthly
review may be initiated because evaluations have not been returned in a timely fashion. If an educational
concern exists, the resident’s advisor or the Program Director will inform the resident.
3. Administrative Status: If a resident is assigned this academic status level, he or she is perceived as having
some difficulty in fulfilling academic requirements. The teaching faculty may assess the progress of the
resident in question and, based on his or her overall performance, determine that the resident is likely to
be successful in fulfilling academic requirements provided some adjustments are made. When the
Program Director considers placing a resident on Administrative Status, he must report the matter to the
DIO and/or chair of the GME committee in writing, prior to action. Administrative Status is not considered
an adverse action; it is a formal teaching plan. It is not subject to appeal.
Administrative Status may include:
o
o
Administrative assignment—this level of academic status is assigned for the specific
purpose of focused improvement in one or more areas in which a resident has not yet
achieved the level of competence necessary to fulfill the program’s academic
requirements. Examples include repeating a clinical rotation for which the resident
received an unsatisfactory composite evaluation, or a substandard in-training exam score.
Administrative leave—this level of academic status is assigned for the immediate
correction of deficiencies in academic requirements. An example would be correction of
significant medical records deficiencies or delinquencies.
4. Probationary Status: This is considered an adverse academic status of a serious degree, wherein the
resident has demonstrated clear failure to meet the academic requirements of the program, and in which
the possibilities of remediation or failure (termination or non-renewal of a resident’s training agreement)
coexist. When the Program Director is considering implementation of Probationary Status for a resident, he
should present the matter to the DIO and/or chair of the GME committee for review and guidance. The
Program Director must report the implementation of Probationary Status to the Texas Medical Board (TMB)
within the reporting period required by the TMB. Residents will be placed on probation when their
academic or nonacademic performance has indicated they may not be able to continue in the residency
program without jeopardizing patient care of departmental function. Residents may be placed on
probation if they are not making satisfactory progress toward meeting the ACGME Competencies.
Residents who are placed on probation will be informed in writing of the reasons for probation. A faculty
member—usually the faculty advisor—will supervise the probation under the overall supervision of the
Program Director. Further problems that arise during the probationary period—including failure to improve
performance—are grounds for immediate termination. Residents on probation may be placed on month-tomonth contracts. Residents will always be informed of being placed on probation, and at their request, may
have a hearing by the Clinical Competency Committee with their advisor present. Residents on probation
will be reviewed at each meeting of the Clinical Competency Committee. Procedures for appeal of
probation are outlined in the policies of the university: http://uthscsa.edu/gme/policies (Policy 2.1.10)
70
5. Suspension: A resident placed on suspension is temporarily removed from all direct patient care and
educational program activities until otherwise notified. This may be implemented at any time for academic
or non-academic reasons if the Program Director has reason to believe patient care may be in jeopardy.
6. Termination: The resident is dismissed from the educational program. The resident may appeal the
decision via the University institutional appeals process. Pending the outcome of these appeals, residents
will not be permitted to work or participated in any residency activities.
The residency Program Director unilaterally may institute disciplinary action or place a resident in any of the above
categories if, in his opinion, circumstances merit such an action. These decisions will be reviewed during the
following Clinical Competency Committee meeting. If necessary, the residency Program Director may call an
emergency meeting of the Clinical Competency Committee. Probation and Termination must be reported to the
Texas State Board of Medical Examiners.
Program Evaluation
Residents anonymously complete an overall evaluation of the faculty annually. They also complete anonymous,
electronic evaluations for each attending physician on rotations at the completion of each block. Both of these
evaluation tools are reviewed by the Program Director who makes appropriate changes or interventions as
indicated. Results of resident evaluation of individual faculty are reviewed, in aggregate, by the faculty on a
quarterly basis. There is also an informal feedback mechanism for residents having difficulty with a particular
supervising faculty during their support group sessions in which residents discuss problems. These groups are
attended by non-evaluating members of the residency who have at times been asked by residents to bring
confidential information to the Program Director about a faculty member’s performance.
Residents are required to complete an anonymous, detailed rotation evaluation for each block rotation. These are
reviewed by the program director and in aggregate by the individual faculty who supervise those curricular areas.
Annual Review of Program Effectiveness
The Annual Review of Program Effectiveness addresses a wide range of data related to the education of residents
and the practice. Survey data from residents and faculty are included in the Review. The Review also includes a
review of the curriculum. An Action Plan is developed for improvement of the program.
71
RESIDENT SUPERVISION, WORK ENVIRONMENT, & DUTY HOURS
Supervision
I.
Introduction:
This policy will establish the minimum requirements for Family Medicine resident supervision in
teaching hospitals and outpatient clinical facilities associated with the University of Texas Health
Science Center at San Antonio (UTHSCSA) and affiliated organizations.
II.
Levels of Supervision:
To ensure oversight of resident supervision and graded authority and responsibility, programs must
use the following classification of supervision:
Direct Supervision: The supervising physician is physically present with the resident and patient.
Indirect Supervision, with direct supervision immediately available: The supervising physician is
physically within the hospital or other site of patient care, and is immediately available to provide
Direct Supervision.
Indirect Supervision, with direct supervision available: The supervising physician is not physical present
within the hospital or other site of patient care, but is immediately available by means of telephonic
and/or electronic means, and is available to provide direct supervision.
Oversight: The supervising physician is available to provide review of procedures/encounters with
feedback provided after care is delivered.
III.
Supervision—General Principles
In all clinical learning environments, every patient has an identifiable supervising attending physician
who is responsible for that patient’s care. This information is readily available to residents on their
rotation daily assignment pages and through the residency faculty scheduling system,
www.whentowork.com. The residency program details the level of supervision provided to residents on
each rotation in the rotation daily assignments. These daily assignments are sent to residents in
advance of each new rotation and are available through New Innovations (www.new-innov.com).
In general, PGY1 residents care for patients with either Direct Supervision or Indirect Supervision
with Direct Supervision Immediately Available. The Immediately Available Supervision is in the form of
a faculty physician, faculty nurse practitioner, or an upper level resident. Upper level residents are
assigned supervisory roles only after the Program Director and Faculty have determined they are
competent to provide direct supervision to junior residents in that particular setting. Oversight by a
faculty physician is available for times when the Immediately Available Supervision is a certified faculty
nurse practitioner. Depending on the clinical setting, PGY2 and PGY3 residents care for patients under
supervision ranging from Direct Supervision to Indirect Supervision with Direct Supervision available.
Details regarding the level of supervision for specific educational settings are available below.
IV.
Supervision: Graded Authority and Responsibility
The Core Faculty members meet monthly to review resident progress. The faculty members make
decisions regarding resident supervision levels, resident progression to the next higher level of
training, and procedural competence. Resident classes are reviewed approximately every three
months with a final decision regarding progression to the next level of training made annually.
In addition, faculty members evaluate the supervisory skills of residents on several key rotations using
a set of six criteria. The core faculty members review these specific supervisory evaluations quarterly to
determine if a resident is competent to supervise junior residents in that particular setting.
In compliance with Joint Commission requirements, the program makes available to all hospital staff
information regarding each resident’s ability to perform procedures independently. The core faculty
determines this for each resident and this information is available to hospital nursing staff through a
specific New Innovations login that allows access only to the procedure competence area of the
system.
72
Work Environments
Inpatient Service:
Dr. Fernandez-Falcón is the Director of Family Medicine Inpatient Service (IPS) and is responsible for developing the
curriculum and overseeing the residents’ experience on the service. Residents rotate on IPS during all three years
of training. The service cares for adult medicine patients, pediatric patients, and GYN patients, and has a co-service
agreement for the Podiatry Service for the management of their patients’ medical problems. Learners from other
schools and departments rotate on IPS, including Podiatry residents, third year medical students, fourth year
medical students, clinical pharmacology students, and physician assistant students.
Resident Responsibilities for Patient Management:
Intern Responsibilities:
Interns are primarily responsible for caring for hospitalized patients under the direct supervision of the upper level
resident and supervising faculty. They will manage patients admitted to the family medicine service, the podiatry
service, and other services that consult family medicine for management.
•
•
•
•
•
The interns have primary responsibility for patient care, including notes (see section below on notes),
developing a management plan, placing orders, and interacting with patients, families, and consulting
services.
Interns are expected to present their patients each day, including the management plan.
Interns are expected to follow their patients throughout the length of the admission, being responsible for
the day to day management, follow up, procedures, consultations, and discharge planning under the close
supervision of the upper level resident and supervising physician.
The intern is responsible for writing a discharge summary on all patients they followed within 24 hours of
discharge and sending this by Secure Health Messaging (Save/Forward) to the patient’s PCP.
The intern should report any concerns to the upper level resident on service. If issues are not resolved in
that way, the intern can then report to the supervising faculty member.
Upper Level Resident Responsibilities:
Upper level residents are responsible for overseeing the day-to-day management of patients admitted to the service
and supervising their interns’ work.
•
•
•
•
•
•
•
•
The upper level resident will attend and lead the morning rounds daily.
The upper level resident will manage the interns’ work load by assigning patients, evaluating “cross cover”
needs, and assist the interns by performing intern-level work when the interns are too busy to manage their
workload safely. This includes ensuring that the interns work within the required duty hours regulations and
that interns are released from the hospital in time to get to other scheduled clinical or learning sessions.
The upper level resident will evaluate each new patient admitted to assess clinical findings and evaluate
the appropriateness of the intern’s assessment and plan. This includes writing their own H&P or reviewing,
editing, and attesting the intern’s H&P. In either case, the resident will discuss the plan with the intern and
provide feedback.
For patients with more complicated clinical conditions, the supervising resident is expected to collaborate
more closely with interns in the patient management. Otherwise, the upper level resident should allow the
intern to develop and present his or her own management plan during morning rounds.
The upper level resident should be aware of all major findings, consultant’s recommendations, and change
in status of any patient at all times.
The upper level resident is to provide teaching to the junior learners on the team, including leading the
knowledge acquisition of the team by identifying knowledge gaps and seeking evidence-based information
to share with the team.
If a third year student is on service, the upper level resident will orient the student to the service and assign
the student patients based on his/her ability.
If a fourth year student is on service, the upper level resident will be responsible for managing that
73
•
•
•
•
•
student’s patients, including seeing those patients, reviewing the student’s notes and providing feedback,
and writing notes and orders on those patients.
The upper level resident is responsible for responding to the E.D. for admissions in a timely fashion.
The upper level resident is responsible for ensuring interns notify outpatient Family Medicine PCPs when
their patients are admitted to and discharged from the hospital.
The upper level resident is responsible for safe patient handoffs to the Night Hospital Physician team.
The upper level resident is responsible for ensuring all residents on the IPS team have access to EPIC.
The upper level resident should report any concerns to the supervising faculty. If issues are not resolved in
that way, the upper level can report directly to Dr. Poursani.
Patient Notes:
1. Every patient will have at least one thorough H&P, Consult or Acceptance Note. An upper level writing the
H&P or Acceptance Note can use an SD or FD Sunrise format. Interns must use SD H&P format. If the
intern writes the H&P, the upper level must review it, edit it for accuracy and completeness, sign it, and
provide the intern feedback. The upper level will be responsible for the content of the H&P ensuring the
accuracy of all information written in that document. The H&P should be Saved/Forwarded to the
outpatient PCP by Secure Health Messaging.
2. H&P should be thorough and include the following information:
a. HPI: This should cover at least 4 elements of the history of present illness (location, onset,
duration, severity, quality, context, timing)
b. Past Medical History: This should be a complete list of medical problems
c. Past Surgical History: A complete list of surgeries & dates when available
d. Past Social History: Comprehensive social history
e. Family History: Comprehensive family history
f. ROS: Cover at least 10 organ systems (Constitutional, ENT, Eyes, Neck, CV, Resp, GI, GU,
Endocrine, Skin, Psych, Neuro, MuscSkeletal)
g. Exam: This should be a comprehensive head-to-toe exam itemizing at least 8 of the above organ
systems.
h. Assessment/Plan: This should focus on issues pertinent to the hospitalization, including the main
reason for hospitalization and the planned management for any relevant comorbidities. Other
outpatient medical problems should be listed with their current status.
3. For the daily note of a patient who is admitted after midnight, interns must still see these patients each
morning. Interns should append the H&P after rounds to reflect any updates in patient status, new results,
and changes to the plan. This must be done by 2pm.
4. For daily notes on established IPS patients, consult patients or patients admitted prior to midnight, interns
should start the progress notes after seeing the patients in the morning. These notes need to be started
before morning rounds and marked Incomplete. The note should be completed before leaving the hospital
and not later than 2pm.
5. Daily notes should be brief and include the following information:
a.
b.
c.
History: This should include only a brief update of any changes since the last note on record. Keep
it simple and pertinent.
Exam: Examine and document at least 2 organ systems; the most relevant organ system should be
detailed with at least 2 organ systems; the most relevant organ system should be detailed with at
least 3 elements of the physical exam.
Assessment/Plan: This should focus on issues pertinent to the hospitalization, including the main
reason for hospitalization and any relevant comorbidities. You can either click in the labs and
studies that are relevant to that day’s care or mention them with each problem in the
Assessment/Plan.
In general, daily progress notes should not include issues that are only relevant to the
74
outpatient/ambulatory care of the patient. These issues should be mentioned in the H&P and the
discharge summary only.
6. All patients, including podiatry patients, will have a Family Medicine Discharge Summary. The discharge
summary can serve as the daily note as long as it includes the vital signs, physical exam, and relevant labs
& studies from the day of discharge.
7. All discharge summaries need to be on file within 24 hours of discharge. The discharge summary should be
Saved/Forwarded via Secure Health Messaging to the outpatient PCP and the provider who will be seeing
the patient for hospital follow up.
8. If an intern anticipates that a discharge of a patient they have been following is scheduled for the next day
and that will be the intern’s day off, that intern should outline the discharge summary, saving the postdated Sunrise record as Incomplete or emailing the Word document to the intern who will cover the patient
the next day.
9. Upper levels will write Transfer Notes on patients being transferred to another service.
10. An upper level (either 2nd or 3rd year) will co-manage patients with all fourth year medical students. This
responsibility includes writing an H&P and daily progress notes, and providing the MS4 feedback.
Guidelines for documenting in Sunrise EMR:
The goal is to have accurate and complete notes that will help us provide excellent patient care.
1. Any copy-forwarded or copy-pasted text must be text that you originally wrote yourself. You are never to
copy-forward of copy-paste an sections of previous notes that you did not author with the exception of
Results, Social History, Family History, and Birth/Pregnancy History. If you copy-forward any of these
sections, you must review the information with the patient to ensure its accuracy and currency.
2. All acronym expansions and copy-pasted text must be carefully and thoroughly edited and updated to
ensure that it accurately reflects the current clinical situation.
3. The Assessment and Plan section must be carefully updated daily to reflect current care.
There will be a NO TOLERANCE POLICY instituted for copying and pasting unless it is permitted as above.
Residents found violating these rules will receive an automatic Failure for that rotation, even after the first
offense.
Transitions of Care
A number of transitions of care/patient handoffs occur on the Inpatient Service:
1. Daily Resident-to-Resident: Day Team (Upper Level resident) to and from Night Team (team of two
residents).
• Patient handoffs will be face-to-face. All three residents will be together for each sign out at 6 AM
and 6 PM.
• The resident(s) signing out patients to the new team will stand at the White Board and review
patients one at a time. The team assuming care of the patient will take notes on the Rounding
Report of all key items regarding each patient.
• The resident giving report will review all AC3UTE items for each patient (see appendix)
2. End of Rotation Resident-to-Resident: Upper Level to Upper Level
• Patient handoffs will be face-to-face between the upper level signing out the team to the next
upper level. When possible, both the PGY2 and PGY3 residents coming onto the IPS should be
present; at the very least, the upper level coming to cover the service the next day should be
present.
• The resident signing out patients to the new upper level will stand at the White Board and review
patients one at a time. The resident assuming leadership of the team will take notes on the
Rounding Report of all key items regarding each patient.
75
•
•
The resident giving report will review all AC3UTE items for each patient (see appendix).
The resident giving report will review intern patient assignments and brief the incoming
upper level resident on any issues related to the team.
3. From FHC providers regarding direct admissions to IPS
• Patient handoffs will typically occur over the phone
• Residents sending an FHC patient for direct admission are to contact the upper level
resident on IPS for review. The admitting resident will present the patient in the SBAR
format to the IPS resident (see Appendix). The FHC resident will document the SBAR
information in the Assessment/Plan area of their Sunrise note.
4. From IPS to the FHC for hospital follow up
• The IPS intern will send the patient discharge summary by Secure Health Messaging to the
provider who will see the patient for follow up in the FHC.
AC3UTE: For Day Team/Night Team resident-to-resident patient handoffs
A
Admission Diagnosis
C3
Code Status, Condition, Comorbidities
U
Updates (changes since admission)
T
To Do (items you would like night float to address)
E
Expectations (if/then scenarios and expectations
SBAR: for handoffs from FHC providers admitting to IPS:
76
Supervision of Residents
Residents are supervised by two faculty members—a faculty physician and a faculty Certified Nurse Practitioner—
during their IPS rotations. Residents can access the information about which faculty member is assigned to the
Inpatient Service in the faculty scheduling system, www.whentowork.com. Faculty provide indirect supervision with
direct supervision immediately available from 9am-5pm every day. At all other times, faculty provide indirect
supervision with direct supervision available, and the Upper Level Resident—who has been cleared by faculty to
serve as immediately available supervising physician on IPS—supervises the junior resident.
Faculty provide direct supervision of all routine procedures the resident perform on patients admitted to the
Inpatient Service.
Circumstances and events in which residents must communicate with supervising faculty members:
Residents must communicate as soon as possible with the appropriate supervising faculty member for any of the
situations listed below. Residents should not compromise patient safety or quality care for these communications,
but should not delay them once the patient is stabilized.
• Any delay in admission—inform IPS faculty about the basis of delaying the admission (additional test,
requesting consult, requesting higher level of care, etc.)
• Admitting an unstable patient to the floor per another team OR ER request.
• Any pediatric admission less than age 18.
• Transferring patient to CCU or MICU
• Unexpected death of a patient
• Patient or his/her family requesting face to face meeting to discuss care
• Patient requesting to leave AMA or refuse necessary care AMA
• DNR discussion/request
• Request by another specialty’s faculty to speak with faculty
• Refusal of care by consulting team or specialty study service
• Plan to send a patient home from the ER
• Any time the resident feels uncertain regarding their abilities, the patient’s condition or the plan of care.
Other Policies & Procedures
Continuity of Care for Family Medicine Patients on IPS:
1. Admitting resident will use the patient’s statement or IDX/Sunrise to identify the patient’s Primary Care
Provider (PCP).
2. Admitting resident will use the Save/Forward function of the Sunrise note to forward the admission note to
the PCP.
3. If the PCP is a PGY2 or PGY3 resident, the admitting resident will determine if that resident is on a rotation
allowing him/her to round on his/her patient in the morning for continuity purposes (labeled “CP” on the AtA-Glance). If so, the admitting resident will page or call the PCP. If the continuity resident PCP is available to
see this patient, they follow the procedure below.
4. If the continuity patient’s resident PCP is not available to round on the patient and is not on vacation or
leave or a day off on the day of admission, the resident PCP should review the patient’s chart and contact
the IPS upper level within 24 hours of admission to discuss his/her patient’s care. The resident PCP must
write at least one note in the patient’s chart, documenting the conversation with the IPS team and any
information pertinent to the patient’s hospital care.
5. The PGY3 resident must ensure that the PCPs and other residents on the IPS follow this protocol.
6. The IPS faculty member is responsible for monitoring the team to ensure that this step is not overlooked.
7. Upon discharge, the inpatient team should Save/Forward the discharge summary to the PCP and to the
provider seeing the patient for his/her hospital follow-up appointment if it is not the PCP.
Procedure for Continuity Resident PCP Rounding on Patients admitted to IPS
1. Continuity PCPs rounding on IPS patients should see their patient in the morning with enough time to
77
accomplish the tasks itemized below.
2. By 8am, the resident PCP will discuss their patient’s care with the PGY2 (or PGY3 if PGY2 is off) on IPS to
develop a management plan for that day and have entered orders based on this discussion.
3. The PGY2 (or PGY3) will see that patient before faculty rounds and cover the patient’s care as events
unfold during the day. The PGY2 (or PGY3) will present the patient to the faculty.
4. The resident PCP should write a note on the patient and have it in the chart by 3pm that day. The PGY2 (or
PGY#) can amend or update that note with current information as necessary. Faculty will attest/sign the
resident PCP’s note.
5. Continuity resident PCPs may choose to round on their patient every day that they are otherwise scheduled
to work. On days that the continuity PCP is off from his or her regular rotation, interns or upper level
residents on IPS will follow the PCP’s patient.
6. If the resident PCP chooses not to round on subsequent days, the patient will be assigned to an intern for
daily IPS care. The resident PCP should continue to follow the patient during the hospital stay, discussing
care with the IPS team when appropriate, and plan to be involved in the discharge care of the patient.
Requirement for Providing Continuity of Care to Hospitalized Patients
1. Each academic year, PGY2 and PGY3 residents are required to see at least three patients on IPS in the
continuity PCP role.
2. Residents are not obligated to accept this task every time they are called and are on a “CP” rotation;
residents may decline this opportunity if it interferes with duty hours requirements or if they have other
personal obligations they must attend to. However, residents must meet this requirement each year, so
they should plan their time wisely.
3. Residents will log these patients’ MRNs, the dates of the IPS visits, and the faculty name in New
Innovations.
4. Residents are welcome to contact the IPS team if they notice one of their patients has been admitted and
the resident PCP is on a “CP” rotation so they can follow their patients.
Continuity of Care for Family Medicine Patients in Obstetrics
1. Residents are required to make an attempt to notify another resident that a continuity patient of theirs has
an impending delivery.
2. If possible, the continuity resident should make an effort to be present for the delivery.
3. Continuity residents are required to participate in the delivery and provide care to the neonate.
4. If a transition in care is required to night call or maternity service, so the continuity resident may return to
scheduled duties or rest prior to returning, a face to face handoff is necessary.
5. The continuity resident must notify the nursery of the attending’s name for admission.
6. The continuity resident must notify the resident to whom care is being transferred of the admission and
provide age, weeks gestation, serologies, prenatal care clinic, weeks at first visit, any complications during
pregnancy (GDM, HTN) and/or delivery, and time of delivery and ROM.
7. If necessary due to work load the backup schedule and protocol will be implemented.
8. The continuity resident should make an effort to examine the baby prior to leaving and relay any concerns
to the resident accepting care of the neonate.
9. Any concerns regarding the care or process should be directed to the on-call faculty for family medicine
neonatal care.
Dress Code:
UHS dress code will be applied for all residents. All residents/interns will wear their clean, white lab coats, if not in
scrubs. Professional dress is required. Men should wear a collared shirt with a tie (tie is optional from June 1October 1). Students are expected to conform to the same dress code.
Time Management:
Residents should manage their time to allow themselves to be on time for scheduled clinics. Residents should
inform the attending physician early in the day of scheduled clinics or other obligations. Residents whose scheduled
IPS time ends before 5pm should inform the attending and the third year, so the work can be finished in a timely
fashion.
78
Geriatrics Inpatient Service
During their PGY2 and PGY3 years, residents rotate on Geriatrics Inpatient Service at the Acute Care of the Elderly
(ACE) unit, located at Christus Santa Rosa Hospital-Medical Center, 1st Floor, 2827 Babcock Rd., SA, TX 78229.
Faculty physicians from the Division of Community Geriatrics staff the unit, directed by Dr. Neela Patel. A variety of
trainees rotate through the unit, including geriatrics fellows, family medicine residents, pharmacy residents, and
medical students. Team meetings occur each weekday, during which the interdisciplinary care team reviews the
individual care plan for each patient on the ACE unit.
Resident Responsibilities for Patient Management
Residents are required to discuss all admissions with the attending and the Inpatient Ph.D. Geriatric Nurse
Practitioner.
ACE Admissions
Patients should be admitted directly to the ACE unit whenever possible. These patients must be seen by a resident
physician upon arrival. Admissions arriving on the floor after 5pm will be admitted by the Nurse Practitioner and/or
the attending. Monitored telemetry patients must be seen and admitted by residents within 2 hours. Non-monitored
patients must be seen within 12 hours or before AM attending rounds, whichever comes first. Residents should
avoid overnight transfers if at all possible. There are no intrahospital (i.e. ICU to floor) transfers allowed after 12
noon.
Outgoing Inpatient Care
Attending rounds begin at 9:15AM. Resident physicians are responsible for being familiar with the ongoing medical
situations of all inpatients and consultation patients under their care at the start of rounds. Residents are required
to check each patient’s MARS (medication sheet) at least every day and be familiar with the key medications that
each patient is on. After the first hospital day, the resident should determine the patient’s discharge level of care
(nursing home, home, home health) and provide that information on rounds. In general, patients should not be
discharged to long term care institutions after 1pm.
ACE IDT (interdisciplinary team) Rounds
The IDT rounds occur promptly at 12:00pm in the IDT conference room on the 10th floor. All IDT rounds are chaired
by nursing, with resident physician input expected. Resident physicians are responsible for being familiar with the
ongoing medical situations of all inpatients and consultation patients under their care at the start of IDT rounds and
be able to give patient care input where appropriate.
Resident Work Hours & Faculty Communication
Residents should be out of the hospital by 7:30pm. On Family Health Center clinic days you must be out by 12:30
pm. If you don’t feel that you will have your work completed by this time, please contact the attending PRIOR to
exceeding this time in order to work out rounds the following day. As duty hours are a serious issue, we will reflect
any violation of this specific policy in the professionalism section of your evaluation. You are required to contact the
attending at ANY hour for ANY questions or concerns.
Emergency Room (ER) Admissions
Initial ER contact will be from the Christus Santa Rosa ER doctor to the on-call resident. The resident will call the
attending, per prior arrangement, via the attending’s personal cell or page to 235-0556. After contact with the
attending, the resident physician will call the ACE unit at 705-6195 and give the initial admissions order. If the oncall resident is still at the hospital, he or she needs to make a quick initial evaluation of the patient in the ER. If the
resident is out of the house, they need to sign the patient out to the on-service resident or the next on-call resident
at the end of their shift.
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Consultations
The third year (PGY3) resident has primary responsibility for consultations. Consultation recommendations are to be
patterned after the information found on the ACE unit cards which are available in the IDT conference room. All
consultation recommendations must be reviewed with the attending prior to the consultation dictation.
Documentation Requirements
Admission Orders:
The PGY2 and PGY3 will review the standardized ACE admission order form with the ACE unit nurse practitioner or
the attending physician on the first day of the rotation. The orders are available on the Unit and on the Rotation
website. Admission orders which are called in should follow this format. The resident must include their beeper
number and duty hours on all admission orders with patient handoff instructions for the next resident also included
in the orders. This is especially important for patients admitted to floors other than the ACE unit.
Progress Notes
Residents are expected to write daily progress notes for all inpatients. Residents cannot refer to a student’s note for
information but must write a standalone note, with the exception of the day of discharge when the notes are
dictated. The standardized ACE transfer form, which is located on the website and in the Unit, will serve as your
note and the student note will serve as the discharge chart note.
All notes must be written or typed on the standardized ACE daily note forms. All notes should refer to the past family
social history from the H&P. The H&P date must be in your note each day. All daily notes must have a review of
systems documented each day as well. Discharge summaries must be written/typed and not dictated.
Consultations and H&Ps can be dictated using the standardized format located on the website.
JAHCO requires all notes and orders be timed and dated. They also must have either a legible signature or a
signature stamp. All orders and notes should have countersignatures by the attending prior to discharge.
Charts & Medical Records
Charts are hard copy. Medical records are on the 1st floor. Before you finish the rotation, please go and complete
any pending medical records work. You are responsible for initial H&Ps and all Discharge Summaries. If you have
more than 2 dictations pending at two weeks after you finish your rotation, your evaluation may be held until they
are completed. Your final evaluation will reflect this. Dictation formats for both H&P and consultations are available
on the website.
Transitions of Care
Cross coverage starts at 6pm and ends at 6am. Residents on the service must begin answering calls at 6am. All
patients must be checked out to the cross covering provider to ensure good patient care.
Evening check out calls are the responsibility of the third year (PGY3) ACE resident. The IPS resident must call the
night call provider (either the covering resident or the Geriatric Nurse Practitioner) to check out the patients on the
service prior to being relieved of their responsibilities. The third year (PGY3) ACE resident is also required to call
back in the AM to receive the service back.
A verbal check out must occur each time coverage changes, even if the patient status does not. If the PGY3 ACE
resident is unable to make contact with the night cover, inform the IPS attending that AM. The PGY3 ACE resident
must also communicate with faculty attending before going off call each day at 6pm. A written handoff, using the
standardized ACE checkout form, is required.
The third year (PGY3) ACE resident must never leave the hospital and become unavailable, for whatever reason,
without checking out the service to either the night call, fellow, or attending. Violation of this policy may result in
an automatic failure for lack of professionalism.
80
General Guidelines, as reflected in the ACE checkout form include:
• Patient name, age, code status and allergies.
• Admission diagnosis, past medical history and comorbid illnesses
• Short summary of hospital course
• Current Medications including any recent changes
• Pending labs and films that must be reviewed overnight
• Incoming patients not seen and pending floor discharges
Please see appendix for recommended patient handoff procedure using SBAR.
Resident Supervision
Attending Geriatrician
The staff attending geriatrician is ultimately responsible for the clinical care of all patients on his service. It is the
staff geriatrician’s responsibility to delegate clinical responsibilities to resident physicians in a manner consistent
with patient safety standards and the concept of graded increases in clinical responsibility in clinical responsibility
for resident physicians based on their level of training and experience. Decisions regarding the level of resident
participation in an individual patient’s care are the responsibility and the prerogative of each individual attending
geriatrician. Attending geriatricians are available on the site at the ACE unit from 9-5 Monday through Friday and on
Saturday and Sunday mornings. Indirect supervision by telephone is available 24 hours a day/7 days a week for
both nursing home care and ACE unit care. The attending geriatricians also provide direct on site supervision of
residents in the UT Medicine Senior Health outpatient clinic and the teaching nursing homes when resident
physicians are present.
Senior Resident (PGY3)
The senior resident is responsible for having a comprehensive understanding of all patients on their service. The
senior residents must be engaged in all clinical decision making for the patients on their service. With the exception
of unusual emergency situations, when seeing patients prior to the staff geriatrician encounter, the senior resident
should formulate his/her own management plan prior to consulting with staff for presentation.
Junior Residents (2nd Year, visiting residents)
Junior residents are assigned specific duties in tandem with the senior resident as the primary resident physicians
providing direct medical care to patients on the geriatrics service. Junior resident are directly supervised by the
attending geriatrician and are assigned graded responsibility for patient care. The individual staff geriatrician and
the nurse practitioner coordinator for the ACE oversee the integrated resident team, and ensure appropriate levels
and quality of clinical supervision. For each patient, ultimate responsibility and management prerogatives are those
of the staff geriatrician.
Circumstances & Events Communications
Resident physicians must communicate with the appropriate staff geriatrician to ensure that a clear understanding
exists between the resident physicians and the staff geriatrician regarding clinical management plans, including the
role residents will play in the actual clinical care delivered to each elder patient. Direct communication is not
immediately required after an expected patient death.
Specific communications must occur when the attending geriatrician is not immediately available in the following
situations:
• Transfers of patients from long term care (ALs, SNFs, NHs) and the hospital
• Transfer of patients to the telemetry unit, CCU or ICU
• At the time of admission
• Prior to any procedure
• Prior to initiating therapy based on consultant opinion.
• Any time the resident feels uncertain regarding their abilities, the patient’s condition or the plan of care.
Other Policies & Procedures
81
Third Year Medical Students
The PGY2 resident will be responsible for orienting medical students to the service. The students are responsible for
rounding on the patients you have assigned to them, presenting their patients to the attending and writing a note on
each patient. Medical students should be encouraged to do new admission workups and mental status evaluations.
The students are also to assist the resident with getting lab results, running down radiographs and helping the
patient care activities run smoothly. The student’s note does not substitute for the resident note except on the
patient’s day of discharge, as noted above. Also, medical students should not be dismissed before the resident’s
work is completed if they can continue to be of service to the resident.
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SBAR
For New Symptoms, Signs and Other Changes in Condition
Physician/NPIPA Communication and Progress Note
INTERACTII
Before Calling MD/NP/PA:
0 Evaluate the resident and complete the SBAR form (use "N/A" for not applicable)
0Check VS:BP, pulse,respiratory rate, temperature, pulse ox, and/or finger stick glucose if indicated
0 Review chart: recent progress notes.labs, orders
0 Review relevant INTERACT II Care Path or Acute Change in Status File Card
0 Have relevant information available when reporting (i.e.resident chart, vitalsigns,advanced directives such
as DNR and other care limiting orders,allergies,medication list)
S
SITUATION
The symptom/sign/change I'm calling about is -----------------------This started.
This has gotten (circle one) worse/better/stayed the same since it started
Things that make the condition worse are ------------------------Things that make the condition better are
Other things that have occurred with this change are----------------------
B BACKGROUND
Primary diagnosis and/or reason resident is at the nursing home -----------------­ Pertinent
history (e.g.recent falls,fever.decreased intake,pain, SOB, other) -------------Vital signs BP
Pulse Oximetry
HR
% On RA. on 02 at
RR ------- Temp
Umin via.
(NC, mask)
Change in functioll1 or mobility ----------------------------­ Medication changes
or new orders in the last two weeks -------------------­ Mental status changes
(e.g.confusion/agitation/lethargy)
GI/GU changes (cricle) (e.g.nausea/vomiting/diarrhea/impaction/distension/decreased urinary outpuVother)
Pain leveUiocation
Change in intake/llydration
Change in skin or wound status ----------------------------Labs -------------------------------------- Advance directives (circle)
(Full code, DNR, DNI, DNH,other,not documented)
Allergies
Any other data----------------
A ASSESSMENT (RN) OR APPEARANCE (LPN)
(For RNs): VI/hat do you think is going on with the resident? (e.g.cardiac, infection, respiratory,urinary,dehydration,
mental status change?) I think that the problem may be
Iam not sure of what the problem is, but there had been an acute change in condition.
(For LPNs):The resident appears (e.g. SOB,in pain1, more confused)----------------
-OR
R REQUEST
Isuggest or request (check all that apply):
0 Provider visit (MD/NP/PA)
0 Lab work, x-rays,EKG,other tests
0 IV or SC ftuids
0 Other (specify)
0 Monitor vitalsigns and observe
0Change in current orders
0 New orders ----------0 Transfer to the lhospital
Staffname
.RN/LPN
Reported to:Name
(MD/NP/PA) Date
If to MD/NP/PA,communicated by:
Resident name
0 Phone
0 In person
(Complete a progress note on the back of this fonn)
"2010FAU
83
/
/
Time
.a.m./p.m.
Progress Note
0 Family or health care proxy notified
Return call/new orders from MD/NP/PA
Signature
, N/LPN
R
Resident Name
Date
/
Date
/
/
/
/
Time
/ Time
_
"2010FAU
Updatod ..tlnuary 2011
84
/
AM/PM
/
AM/PM
Maternity Service
Dr. Marcy Wiemers directs the Family Medicine Maternity Service and is responsible for developing the curriculum and
overseeing the residents’ experience on the service. Residents rotate on Maternity Service during their third year. The service
cares for pregnant women in the Antepartum, Labor & Delivery, and Postpartum units, and for these women’s newborn babies
in the Newborn Nursery and Level 2 Nursery. Residents also evaluate family medicine patients in the GYN triage unit during
their Maternity Service rotations. Medical students also rotate on the Family Medicine Maternity Service.
Patients seen at Kenwood, Salinas, or the FHC Prenatal Clinics count towards continuity patient numbers.
Resident Responsibilities for Patient Management
Residents are responsible for all aspects of patient care on the Maternity Service, including evaluating patients, writing notes
and orders, doing exams and procedures in a timely manner, educating the mother prior to discharge, and doing all of the
appropriate discharge planning and notes.
Residents round with the Maternity Service faculty every morning on L&D, the Antepartum and Postpartum units, and in the
nurseries.
Residents perform procedures under direct faculty supervision for all patients admitted to the Maternity Service. Procedures on
pregnant women include, but are not limited to, cervical exams, sterile speculum exams, sonograms, amniotomies, fetal scalp
electrode placement, intrauterine pressure catheter placement, vaginal deliveries, episiotomy/laceration repairs, and first assist
on C-sections and tubal ligations. Newborn Nursery procedures include phototherapy and circumcisions.
Guidelines for Documenting in Sunrise EMR:
The goal is to have accurate complete notes that will help us provide excellent patient care.
1. Any copy-forwarded or copy-pasted text must be text that you originally wrote yourself. You are never to copy-forward of
copy-paste an sections of previous notes that you did not author with the exception of Results, Social History, Family
History, and Birth/Pregnancy History. If you copy-forward any of these sections, you must review the information with
the patient to ensure its accuracy and currency.
2. All acronym expansions and copy-pasted text must be carefully and thoroughly edited and updated to ensure that it
accurately reflects the current clinical situation.
3. The Assessment and Plan section must be carefully updated daily to reflect current care.
There will be a NO TOLERANCE POLICY instituted for copying and pasting unless it is permitted as above. Residents found
violating these rules will receive an automatic Failure for that rotation, even after the first offense.
Transitions of Care
A number of transitions of care/patient handoffs occur on the Maternity Service:
1. Daily Resident-to-Resident: Day Team (Maternity Service resident) to and from Night Team (team of two residents).
• Patient handoffs will be face-to-face. All three residents will be together for each sign out at 7 AM and 7 PM.
• The resident(s) signing out patients to the new team will review each patient on the service and hand over the
patient tracking card.
2. From FHC/Kenwood/Salinas providers regarding patients being sent to OB Triage
• Patient handoffs will typically occur over the phone
• Residents sending a patient from the FHC, Salinas or Kenwood for evaluation in OB Triage should contact the
Maternity Service resident. The outpatient resident will present the patient in the SBAR format to the Maternity
resident (see Appendix). The outpatient resident will document the SBAR information in the Assessment/Plan
area of their Sunrise note.
3. From Maternity Service to the FHC/Kenwood/Salinas for follow up
• The resident will send the patient discharge summary by Secure Health Messaging to the provider who will
see the patient for follow up in the FHC.
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Supervision of Residents
Residents are supervised by a faculty physician, who provides indirect supervision with direct supervision immediately available.
Most times, a Family Medicine faculty member is the supervising faculty. Residents can access the information about which
faculty is assigned to the Maternity Service in the faculty scheduling system, www.whentowork.com. When a Family Medicine
faculty is not scheduled to cover the Maternity Service, the OB/GYN on call faculty provides indirect supervision with direct
supervision immediately available.
All procedures are directly supervised by the faculty physician.
Circumstances and events in which residents must communicate with supervising faculty members:
Residents must communicate as soon as possible with the appropriate supervising faculty member for any of the situations
listed below. Residents should not compromise patient safety or quality care for these communications, but should not delay
them once the patient is stabilized.
•
•
•
•
Anytime a patient arrives in OB or Gyn Triage
For any patient who is admitted in labor.
Any patient requesting to leave or refuse treatment AMA.
Any time the resident feels uncertain regarding their abilities, the patient’s condition, or the plan of care.
Other Policies & Procedures
Dress Code: All residents will wear clean scrubs while on duty for Maternity Service.
Guidelines for Claiming Deliveries:
1. All deliveries are to be logged in New Innovations, in the Procedure Logger module.
2. No more than two residents can claim a single delivery. One may claim the role of Delivering Resident, and the other
may claim the role of Supervising Resident.
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3. Each delivery log should include as a minimum: Patient ID (MRN), Gender, Date of Birth, Date Performed, Location,
Procedure, Role in the Procedure, and Supervisor.
a. If the Supervising faculty’s name is not available in the drop down menu or is from the OB department, select
Mark Nadeau, MD. In the comment box, include information about who was the actual attending for the
delivery.
4. A delivery must be logged in the Procedure field as either a Continuity or Non-Continuity delivery in the following
categories: Cesarean sections, Cesarean section Assist, Low Forceps, Vacuum Extraction, or Vaginal.
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Night Hospital Physician Service & Night Hospital Physician Home Call
Dr. Cristián Fernandez-Falcón is responsible for developing the curriculum and overseeing the residents’ experience on the
Night Hospital Physician service. Residents rotate on Night Hospital Physician during all three years of training. The service
cares for the patients who are on the Family Medicine Inpatient Service (IPS) and the Family Medicine Maternity Service
overnight. Sunday through Thursday nights are covered by a team of two residents. Friday and Saturday nights are crosscovered by residents already on the day services for IPS and Maternity. The Night Hospital Physician residents are expected to
be awake and working for the entire night.
Resident Responsibilities for Patient Management
Residents report for Night Hospital Physician to the IPS call room at 6pm, where they receive a structured patient handoff of the
IPS patients. Transition of care for Maternity Service patients will occur at 6:45 pm, either in the IPS work room or in Labor &
Delivery, depending on whether there are patients in active labor. BOTH members of the Night Hospital Physician team should
be present for both sign outs.
At 6am, the Night Hospital Physician (NHP) team will provide a structured patient handoff to the IPS senior resident. The NHP
team should speak to the IPS faculty before 7am to discuss new patients and events from the night. The NHP team provides a
structured patient handoff to the Maternity Service at 7am.
Patients in Active Labor:
The NHP team should call in a continuity PGY2 or PGY3 resident to do the delivery. Continuity residents are expected to arrive at
the hospital within 45 minutes of being called unless they meet the following criteria:
•
•
•
•
The continuity resident is on an “essential service” and has to report within 10 hours the next day. Essential services
are: CCU, OB, ER, IPS, Maternity Service, Geri IPS, Inpatient Pediatrics, Inpatient or Outpatient Surgery, FHC and Well
Child Clinic, and Gyn clinic.
The continuity resident is on vacation or at a conference.
The continuity resident has already logged their 10 required continuity deliveries AND their 40 total deliveries.
The continuity resident has other extenuating circumstances, such as having a minor at home without any other
childcare. These circumstances must be communicated to the Associate Program Director (Dr. Wiemers) via email
within 24 hours.
In case there is no resident available, one of the NHP residents will manage the labor and do the delivery.
Night Hospital Physician Home Call:
If NHP Service gets excessively busy overnight beyond what two residents normally should be expected to manage while
ensuring patient safety, the NHP team can all in the NHP Home Call resident (schedule available in New Innovations). The NHP
Home Call resident is required to arrive at the hospital within 30 minutes of being called. In order to preserve continuity of care
among the already admitted patients on the two services, the home call resident will be expected to cover short-term needs in
the following priority:
1. Manage labor & delivery
2. Do new admission(s) to IPS
Once the workload has returned to a manageable level, the home call resident should be excused to go home; if the NHP team
needs additional help, they should call the same resident in. The home call resident is expected to go to their scheduled
session the next day. This does not violate duty hours unless the resident would work more than 80 hours that week.
IPS Patient Notes:
For established patients on the services: The NHP team should document a brief patient note each time they are called to
evaluate an established patient with a new or worsening problem.
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For new admissions or consults to the IPS: The NHP team should document a single H&P, Consult, or Acceptance Note. An
upper level writing the H&P or Acceptance Note can use an SD or FD Sunrise format. Interns must use SD H&P format. If the
intern writes the H&P, the upper level must review it, edit it for accuracy and completeness, sign it, and provide the intern
feedback. The upper level will be responsible for the content of the H&P, ensuring the accuracy of all information written in that
document. H&P should be thorough and include the following information:
•
•
•
•
•
•
•
•
HPI: This should cover at least 4 elements of the history of present illness (location, onset, duration, severity,
quality, context, timing)
Past Medical History: This should be a complete list of medical problems.
Past Surgical History: A complete list of surgeries and dates when available
Past Social History: Comprehensive social history.
Family History: Comprehensive family history.
ROS: Cover at least 10 organ systems (Constitutional, ENT, Eyes, Neck, CV, Resp, GI, GU, Endocrine, Skin,
Psych, Neuro, MuscSkeletal)
Exam: This should be a comprehensive head-to-toe exam itemizing at least 8 of the above organ systems.
Assessment/Plan: This should focus on issues pertinent to the hospitalization, including the main reason for
hospitalization and the planned management for any relevant comorbidities. Other outpatient medical
problems should be listed with their current status.
Maternity Patient Notes:
For established patients on the services:
The NHP team should document a brief patient note each time they are called to evaluate an established patient with a new or
worsening problem. When following a patient in labor, the team should update the whiteboard in L&D and make their hourly
notes on the paper labor record on the front of the patient chart. If a major event or change in the laboring patient’s status
occurs, the resident should enter a note in the EMR as well.
For new admissions or triage visits:
Tuesday and Wednesday the NHP team will be called to L&D Triage or Gyn Triage when our patients present to those places.
The team will also be responsible for newborn H&Ps for babies delivered anytime during NHP. This includes babies delivered by
the OB service Thursday night through Monday night.
The team should document a single H&P or triage note. Please use the structured note format for L&D triage notes and for
patients admitted from Gyn Triage. A free text note may be used for patients seen and discharged from Gyn Triage. Please also
use the structured newborn H&P note including the structured physical exam section. If a baby comes in for a nursery clinic visit
on NHP time, a free text notes should be used.
If the intern writes the H&P, the upper level must review it, edit it for accuracy and completeness, sign it, and provide feedback
to the intern. The upper level will be responsible for the content of the H&P, ensuring the accuracy of all information written in
that document. H&P should be thorough and include all of the information that is in the structured format. This includes past OB
history for women and weights and measures (including percentile rank), APGAR and delivery history for the babies.
Please make a white data card for every patient seen and be prepared to pass those cards on to the next resident at check out.
Circumstances and events in which residents must communicate with supervising faculty members:
Residents must communicate as soon as possible with the appropriate supervising faculty member for any of the situations
listed below. Residents should not compromise patient safety or quality care for these communications, but should not delay
them once the patient is stabilized.
For IPS Patients:
•
Any delay in admission—inform IPS faculty about the basis of delaying the admission (additional test, requesting
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•
•
•
•
•
•
•
•
•
•
•
consult, requesting higher level of care, etc.)
Admitting an unstable patient to the floor per another team OR ER request.
Any pediatric admission less than age 18.
Transferring patient to CCU or MICU
Unexpected death of a patient
Patient or his/her family requesting face to face meeting to discuss care
Patient requesting to leave AMA or refuse necessary care AMA
DNR discussion/request
Request by another specialty’s faculty to speak with faculty
Refusal of care by consulting team or specialty study service
Plan to send a patient home from the ER
Any time the resident feels uncertain regarding their abilities, the patient’s condition or the plan of care.
For Maternity Service Patients:
•
•
•
•
Anytime a patient arrives in OB or Gyn Triage
For any patient who is admitted in labor.
Any patient requesting to leave or refuse treatment AMA.
Any time the resident feels uncertain regarding their abilities, the patient’s condition, or the plan of care.
Other Policies & Procedures
Dress Code: All residents will wear clean scrubs while on duty for Night Hospital Physician Service.
Guidelines for Claiming Deliveries:
1. All deliveries are to be logged in New Innovations, in the Procedure Logger module.
2. No more than two residents can claim a single delivery. One may claim the role of Delivering Resident, and the other
may claim the role of Supervising Resident.
3. Each delivery log should include as a minimum: Patient ID (MRN), Gender, Date of Birth, Date Performed, Location,
Procedure, Role in the Procedure, and Supervisor.
a. If the Supervising faculty’s name is not available in the drop down menu or is from the OB department, select
Mark Nadeau, MD. In the comment box, include information about who was the actual attending for the
delivery.
4. A delivery must be logged in the Procedure field as either a Continuity or Non-Continuity delivery in the following
categories: Cesarean sections, Cesarean section Assist, Low Forceps, Vacuum Extraction, or Vaginal.
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The Family Health Center
Dr. Poursani is the Medical Director of the Family Health Center (FHC) and is responsible for ensuring residents meet the RRC
requirements for FHC training. Residents are assigned to one of three modules in the FHC, designated Red, Blue, or Green.
Each module has a faculty physician who serves as Module Director: Dr. Ivy in Red, Dr. Ali in Blue, and Dr. Poursani in Green.
The Module Directors are responsible for overseeing the residents’ experience in the FHC. Residents see patients of all ages in
the FHC during all three years of training. Clinic sessions are four hours long, starting at 8am for morning sessions and 1pm for
afternoon sessions. The FHC is open Monday-Friday. Third and Fourth year medical students rotate in the FHC and are assigned
to work directly with PGY2 or PGY3 residents.
During their intern year, residents must see 165 patients in FHC. Residents are required to see a total of 1650 patients in the
FHC during the three years of residency training. In addition, residents are required to be in clinic seeing patients during at least
40 weeks of each academic year.
In addition to continuity clinic experiences, residents also see patients in other FHC clinic sessions during various block
rotations, including the Bone & Joint Clinic, Counseling Clinic, Excision Clinic, Prenatal Clinic, Psychotropic Clinic, Sports
Medicine Clinic, Vasectomy Clinic, Well Child Clinic, and Women’s Clinic.
Resident Responsibilities for Patient Management
Interns:
Interns start in the FHC seeing 3 patients per session and gradually advance to 5 patients per session over the course of the
first 4-6 months of internship. Interns are in clinic during most of their block rotations, averaging 2 clinic sessions per week.
PGY2 Resident:
PGY2 residents see 7 patients per clinic session for the first half of the academic year and then advance to 8 patients per
session. PGY2 residents are in the FHC on average 3 FHC sessions per week.
PGY3 Resident:
PGY3 residents start with 9 patients per clinic session for the first half of the academic year and then advance to 10 patients
per session. PGY3 residents are in the FHC up to 5 sessions per week.
Residents are responsible for seeing patients in a timely manner, discussing their patients with the assigned faculty preceptor,
documenting their care in the EMR, ordering and necessary studies or labs, and following up with their patient results through
the EMR messaging system.
Residents must complete patient notes by the end of the calendar day on which the patient was seen in the FHC.
In addition, residents are responsible for working as a team to manage patient care tasks. Each module has a “Doc of the Day”
system that designates a resident each day who is responsible for patient phone calls, prescription renewals, and other
paperwork.
Residents are required to check their Secure Health Messaging and Secure Results every day that they are working, regardless
of whether they are in the FHC or not. Access to this patient care messaging system is available on any UHS computer and via
remote logon.
Guidelines for Documenting in Sunrise EMR:
The goal is to have accurate complete notes that will help us provide excellent patient care.
1. Any copy-forwarded or copy-pasted text must be text that you originally wrote yourself. You are never to copy-forward of
copy-paste an sections of previous notes that you did not author with the exception of Results, Social History, Family
History, and Birth/Pregnancy History. If you copy-forward any of these sections, you must review the information with
the patient to ensure its accuracy and currency.
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2. All acronym expansions and copy-pasted text must be carefully and thoroughly edited and updated to ensure that it
accurately reflects the current clinical situation.
3. The Assessment and Plan section must be carefully updated daily to reflect current care.
There will be a NO TOLERANCE POLICY instituted for copying and pasting unless it is permitted as above. Residents found
violating these rules will receive an automatic Failure for that rotation, even after the first offense.
Transitions of Care
Transitions of care/patient handoffs occur for patients in the FHC in a number of ways:
1. Patient getting admitted from FHC to the IPS or Maternity Service: Residents sending an FHC patient for direct
admission are to contact the upper level resident on the hospital service for review. The admitting resident will
present the patient in the SBAR format to the hospital service resident (see Appendix). The resident in the FHC will
document the SBAR information in the Assessment/Plan area of their Sunrise note.
2. Patient getting sent from FHC to ExpressMed or ER: Residents sending an FHC patient to the Express Med or
Emergency Department for further evaluation will complete their Sunrise note prior to the patient leaving the FHC. The
resident will document the reason for transfer in SBAR format in the Assessment/Plan area of their Sunrise note. If
the patient is going to a facility outside UHS, they should ensure that a copy of the visit note accompanies the patient.
3. Patient returning from IPS or Maternity Service to the FHC for follow-up after discharge: In this instance, the resident
on the hospital service will send the patient discharge summary by Secure Health Messaging to the provider who will
see the patient in follow up.
Supervision of Residents
During the first six months of residency, all PGY1 residents who have passed USMLE Step 2-CS and the Orientation OSCE see
patients under indirect supervision with direct supervision immediately available in the form of a faculty preceptor who is
assigned a maximum of four residents per clinical session. During the first six months, PGY1 residents present their patients to
faculty, who then see the patient with the intern to confirm key history and physical examination findings. Faculty have final
approval of the management plan. Faculty members evaluate PGY1 residents after the first six months to determine their ability
to see patients in the Family Health Center under the Primary Care Exemption (PCE) rule.
PGY1 residents who have not passed USMLE Step 2-CS or the Orientation OSCE see patients in the FHC with direct faculty
supervision. This continues until they have successfully demonstrated their clinical skills by means of passing faculty preceptor
evaluations, using the Mini-CEX.
PGY1 residents who have passed the evaluation at six months and PGY2 and PGY3 residents see patients in the FHC under
indirect supervision with direct supervision immediately available in the form of a faculty preceptor who is assigned a maximum
of four residents per clinical session. These residents present their patients and the management plan to the faculty preceptor.
Faculty will see these residents’ patients if the resident requests that or the faculty determines the need to see the patient.
All procedures performed in the FHC and FHC-related clinics are done with direct faculty supervision.
Circumstances and events in which residents must communicate with supervising faculty members:
Residents must communicate as soon as possible with the appropriate supervising faculty member for any of the situations
listed below. Residents should not compromise patient safety or quality care for these communications, but should not delay
them once the patient is stabilized.
•
•
•
Any patient seen by the resident in the FHC must be precepted by the faculty assigned to that resident.
Any critical lab value or study result.
Any time the resident feels uncertain regarding their abilities, the patient’s condition, or the plan of care.
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Other Policies & Procedures
Continuity of Care for Family Medicine Patients on IPS:
1. Admitting resident will use the patient’s statement or IDX/Sunrise to identify the patient’s Primary Care Provider (PCP).
2. Admitting resident will use the Save/Forward function of the Sunrise note to forward the admission note to the PCP.
3. If the PCP is a PGY2 or PGY3 resident, the admitting resident will determine if that resident is on a rotation allowing
him/her to round on his/her patient in the morning for continuity purposes (labeled “CP” on the At-A-Glance). If so, the
admitting resident will page or call the PCP. If the continuity resident PCP is available to see this patient, they follow the
procedure below.
4. If the continuity patient’s resident PCP is not available to round on the patient and is not on vacation or leave or a day
off on the day of admission, the resident PCP should review the patient’s chart and contact the IPS upper-level within
24 hours of admission to discuss his/her patient’s care. The resident PCP must write at least one note in the patient’s
chart, documenting the conversation with the IPS team and any information pertinent to the patient’s hospital care.
5. The 3rd year resident must ensure that the PCPs and other residents on IPS follow this protocol.
6. The IPS faculty member is responsible for monitoring the team to ensure that this step is not overlooked.
7. Upon discharge, the inpatient team should Save/Forward the discharge summary to the PCP and to the provider seeing
the patient for his/her hospital follow-up appointment if it is not the PCP.
Procedure for Continuity Resident PCP Rounding on Patients Admitted to IPS
1. Continuity PCPs rounding on IPS patients should see their patients in the morning with enough time to accomplish the
tasks itemized below.
2. By 8am, the resident PCP will discuss their patient’s care with the PGY2 (or PGY3 if PGY2 is off) on IPS to develop a
management plan for that day and have entered orders based on this discussion.
3. The PGY2 (or PGY3) will see that patient before faculty rounds and cover the patient’s care throughout the day. The
PGY2 (or PGY3) will present the patient to the faculty.
4. The resident PCP should write a note on the patient and have it in the chart by 3pm that day. The upper level resident
can amend or update that note with current information as necessary. Faculty will attest/sign the resident PCP’s note.
5. Continuity resident PCPs may choose to round on their patient every day that they are otherwise scheduled to work. On
days that the continuity PCP is off from their regular rotation, interns or upper level residents on IPS will follow the
PCP’s patient.
6. If the resident PCP chooses not to round on subsequent days, the patient will be assigned to an intern for daily IPS
care. The resident PCP should continue to follow the patient during the hospital stay, discussing care with the IPS team
when appropriate, and plan to be involved in the discharge care of the patient.
Requirement for Providing Continuity Care to Hospitalized Patients
1. Each academic year, PGY2 and PGY3 residents are required to see at least three patients on IPS in the continuity PCP
role.
2. Residents are not obligated to accept this task every time they are called and are on a “CP” rotation; residents may
decline this opportunity if it interferes with duty hours requirements or if they have other personal obligations they must
attend to. However, residents must meet this requirement each year, so they should plan their time wisely.
3. Residents will log these patients’ MRNs, the dates of the IPS visits, and the faculty name in New Innovations.
4. Residents are welcome to contact the IPS team if they notice one of their patients has been admitted and the resident
PCP is on a “CP” rotation so they can follow their patients.
FHC Protocols/Standard Operating Procedures
The FHC has a number of clinic protocols regarding “no show” patients and appointment scheduling. These protocols are on the
FHC Shared Drive accessible by all residents on the UHS system. Residents should follow these protocols.
Sunrise Secure Health Messaging
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Providers and staff throughout the UHS system use the Sunrise Secure Health Messaging system to communicate about
specific patient care issues. These messages are retained in the EMR as part of the patient’s medical record. Residents are to
check their Secure Health Messaging every day they are working and respond to messages in a timely, patient-centered
manner. Faculty preceptors are available to assist residents with these messages either in the FHC or on the family medicine
inpatient services (IPS and Maternity). This system is available on any UHS computer and through remote logon.
Dress Code
Physicians are expected to wear appropriate attire when seeing patients in the Family Medicine Clinics. This means dressing in
the manner that would be expected of a primary care physician seeing patients in any office-based practice or “business dress.”
At a minimum, this should be a dress shirt with a tie and slacks for men (the tie is optional from June 1 to October 1), and
comparable dress for women. Men are excused from wearing a tie during excision, well child, and pedi walk-in clinics. The issue
is showing respect for our patients. Dress that would be inappropriate in a private office is inappropriate in our setting.
Specifically, shorts, T-shirts, blue jeans, sweats, and scrubs are inappropriate attire for seeing patients in the office. If
physicians doing procedures wish to wear scrubs, locker rooms are available in the clinic for changing.
Blouses/shirts MUST be long enough to cover the entire abdomen. Tattoos must not be visible. No culottes or capris may be
worn in clinic or Inpatient Service, or any situation in which there is a possibility of contact with blood/bodily fluid or sharps.
Closed shoes must be worn at all times. No sandals or open-toed shoes in clinic or IPS or any situation in which there is a
possibility of contact with blood/bodily fluids or sharps.
Residents are also expected to have a professional appearance on the Family Medicine Inpatient and Maternity services.
Shorts, t-shirts, and blue jeans are not appropriate attire. Clean scrubs with a clean, white lab coat are appropriate for IPS and
Maternity Service.
In addition, directors of individual clinics may set additional dress requirements with which physicians practicing in those
settings must comply.
Dress code must be adhered to; discrepancies will be documented as lack of professionalism.
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Ambulatory Rotations
Each ambulatory rotation has a designated faculty physician as the point of contact, as outlined on the Rotation Daily
Information available through New Innovations. This faculty physician is responsible for the resident experience on that rotation.
Resident Responsibilities for Patient Management
Residents are responsible for adhering to ethical principles of practicing medicine. Residents must present and have faculty see
all patients whose care they are involved in at ambulatory clinic settings outside of the FHC, Kenwood, and Salinas.
Transitions of Care
Residents should follow the standards of the ambulatory clinic site with regard to transferring the care of a patient to another
facility.
Supervision of Residents
During the first six months of residency, all PGY1 residents who have passed the USMLE Step 2-CS and the Orientation OSCE
see patients while receiving indirect supervision with direct supervision immediately available. Additionally, the preceptor must
see all patients for PGY1 residents during the first six months of training.
PGY1 residents who have passed the evaluation at six months and PGY2 and PGY3 residents may see patients under indirect
supervision with direct supervision immediately available in the form of a faculty preceptor.
For all ambulatory sites outside the FHC, Salinas, and Kenwood clinics, residents must have faculty see their patients prior to
dismissal.
Circumstances and events in which residents must communicate with supervising faculty members:
Residents must communicate as soon as possible with the appropriate supervising faculty member for any of the situations
listed below. Residents should not compromise patient safety or quality care for these communications, but should not delay
them once the patient is stabilized.
•
•
Any critical lab value or study result.
Any time the resident feels uncertain regarding their abilities, the patient’s condition or the plan of care.
Other Policies & Procedures
Residents should follow the specific instructions on their Rotation Daily Assignments in New Innovations.
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Hospital Based Rotations
Each hospital based rotation has a designated faculty physician as a point of contact, as outlined on the Rotation Daily
Information available through New Innovations. The faculty physician is responsible for the resident experience on that rotation.
Many hospital services are led by Chief Residents, who are responsible directly for the Family Medicine residents’ day-to-day
work on the service.
Resident Responsibilities for Patient Management
Residents are responsible for adhering to ethical principles of practicing medicine.
Transitions of Care
Residents should follow the standards of the hospital based site with regard to transferring the care of a patient to another
facility or service.
Supervision of Residents
All PGY1 residents who have passed USMLE Step 2-CS and the Orientation OSCE see patients under indirect supervision with
direct supervision immediately available. PGY2 and PGY3 residents may see patients under indirect supervision with direct
supervision immediately available in the form of a faculty physician, Chief Resident, or other supervising physician as identified
by the specified service.
Circumstances and events in which residents must communicate with supervising faculty members:
Residents must communicate as soon as possible with the appropriate supervising faculty member for any of the situations
listed below. Residents should not compromise patient safety or quality care for these communications, but should not delay
them once the patient is stabilized.
•
•
Any critical lab value or study result.
Any time the resident feels uncertain regarding his or her abilities, the patient’s condition, or the plan of care.
Other Policies & Procedures
Residents should follow the specific instructions on their Rotation Daily Assignments in New Innovations.
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Documentation
Medical Records
The department abides by the medical record policies of each of the hospitals and outpatient facilities with which the program is
affiliated. Records must be completed in a timely manner and must be legible, coherent, truthful, and accurate. Residents must
respond to requests by the medical records department to complete their records in a prompt fashion. The record is owned by
the facility. Any residents who receive a subpoena for records must notify the Program Director immediately.
Prohibition of Copy/Paste in Inpatient Records
Residents must follow UHS policy when using copy/paste on the inpatient service and failure to do so will result in loss of copy/
paste privileges.
Procedure documentation
Documentation of the residency experience is a required part of the program. In many cases, clear documentation of
procedures performed during residency training is used for future hospital privileging. Lack of documentation often results in
denial of privileges to perform procedures. It is also imperative that residents keep track of their procedures including both
continuity and non-continuity deliveries in order to meet requirements for graduation. This information should be updated in
New Innovations on a regular basis—at least monthly—and immediately if requested by the program director.
Each resident is required to document the following procedures in New Innovations:
•
Advance Cardiac Life Support (run code)
•
Excision biopsy of skin lesion and/or mass
•
Arterial puncture
•
Exercise Treadmill Test
•
Assist at surgery (specify procedure
•
Fetal Monitoring, placement of fetal scalp electrode
•
Cast application (specify type)
•
Foreign body removal, eye or ear
•
Circumcision, neonatal
•
Intrauterine pressure catheter, placement of
•
Colonoscopy
•
IUD insertion/removal
•
Colposcopy
•
Joint aspiration/injection
•
Delivery—Caesarean section (continuity)
•
Lumbar puncture—adult & child
•
Delivery—Caesarean section assist (continuity)
•
OB ultrasound for AFI, BPP, fetal presentation
•
Delivery—Low Forceps (continuity)
•
Paracentesis
•
Delivery—Vacuum extraction (continuity)
•
Phototherapy of newborn
•
Delivery—Vaginal (continuity)
•
Placenta removal, manual
•
Delivery—Caesarean section
•
Reduction of dislocation (specify site)
•
Delivery—Caesarean section assist
•
Reduction of fracture (specify site)
•
Delivery—Low Forceps
•
Repair cervical laceration
•
Delivery—Vacuum extraction
•
Thoracentesis
•
Delivery—Vaginal
•
Toenail/Fingernail removal, partial or complete
•
Electrodessication & Curettage
•
Transvaginal ultrasound
•
Endometrial biopsy
•
Trigger point injection
•
Episiotomy/Perineal laceration repair
•
Vasectomy
•
Esophagogastroduodenoscopy
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Call and Duty Hours
Duty hours are defined as all clinical and academic activities related to the residency program, i.e. patient care (both inpatient
and outpatient), administrative duties related to patient care, the provision for transfer of patient care, time spent in-house
during call activities, and scheduled academic activities such as conferences. Duty hours do not include reading and
preparation time spent away from the work site. Time spent moonlighting (this is defined as any voluntary, compensated,
medically-related work performed at any institution) must be counted toward all duty hours rules.
Duty hours do not include time spent on home call, unless you are called in to the clinic site.
Maximum Hours of Work per Week
Duty hours must be limited to 80 hours per week, averaged over a 4-week period, inclusive of all in-house call activities and all
moonlighting.
Maximum Duty Period Length
PGY1 residents must not exceed 16 hours in duration.
PGY2 and above residents may be scheduled to a maximum of 24 hours of continuous duty in the hospital.
•
•
•
It is essential for patient safety and resident education that effective transitions in care occur. Residents may be
allowed to remain on-site in order to accomplish these tasks; however, this period must be no longer than an additional
4 hours.
Residents must not be assigned additional clinical responsibilities after 24 hours of continuous in-house duty.
In unusual circumstances, residents, on their own initiative, may remain beyond their scheduled period of duty to
continue to provide care to a single patient. Justification for such extensions of duty are limited to reasons of required
continuity of care for a severely ill or unstable patient, academic importance of the events transpiring, or humanistic
attention to the needs of a patient or family.
o Under those circumstances, the resident must:
 Appropriately hand over care of all other patients to the team responsible for their continuing care,
and;
 Document the reasons for remaining to care for the patient in question and submit that
documentation in every circumstance to the program director.
o The Program Director must review each submission of additional service, and track both individual resident
and program-wide episodes of additional duty.
Mandatory Time Free of Duty
Residents must be scheduled for a minimum of one day free of duty every week, averaged over a 4-week period. At home call
cannot be assigned on these duty-free days.
Minimum Time Off between Scheduled Duty Periods
PGY1 residents should have 10 hours—and must have 8 hours—free of duty between scheduled duty periods.
PGY2 residents should have 10 hours free of duty, and must have 8 hours between scheduled duty periods. They must have at
least 14 hours free of duty after 24 hours of in-house duty.
PGY3 residents must be prepared to enter the unsupervised practice of medicine and care for patients over irregular or
extended periods.
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This preparation must occur within the context of the 80-hour maximum duty period length, and one-day-off-in-seven
standards. While it is desirable that residents in their final years of education have 8 hours free of duty between
scheduled duty periods, there may be circumstances when these residents must stay on duty to care for their patients
or return to the hospital with fewer than eight hours free of duty.
Circumstances of return to hospital activities with fewer than 8 hours away from the hospital by residents in their final
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year of education will be monitored by the program director.
Violation of Duty Hours
Violation of duty hours is a serious matter. When residents violate duty hours and sign off on these hours in New
Innovations, a duty hours violation will be flagged. The residency program director will immediately contact the resident to
counsel them on the present incident and the impact of any possible future incidents.
Maximum Frequency of In-House Night Hospital Physician
Residents must not be scheduled for more than 6 consecutive nights of Night Hospital Physician.
Maximum Frequency of In-House On-Call
PGY2 residents and above must be scheduled for in-house call no more frequently than every third night, arranged over a 4week period.
At Home Call
Time spent in the hospital by residents on at-home call must count towards the 80-hour maximum weekly hour limit. The
frequency of at-home call is not subject to the every-third-night limitation, but must satisfy the requirement for one-day-inseven free of duty, when averaged over four weeks.
At-home call must not be so frequent or taxing as to preclude rest or reasonable personable time for each resident.
Residents are permitted to return to the hospital while on at-home call to care for new or established patients. Each episode
of this type of care, while it must be included in the 80-hour weekly maximum, will not initiate a new “off-duty period.”
Schedules have been designed to meet ACGME duty hour guidelines. If a resident believes that his or her scheduled
exceeds any of the guidelines, the resident should immediately contact the program director or associate program director,
so the appropriate changes can be made to modify the schedule.
Residents are responsible for cross-referencing their clinic and on-call schedules to identify possible sources of conflict
between duty hours and clinical responsibilities in advance. Any clinics that are cancelled will be made up at the
leadership’s discretion. Repeated instances of last minute cancellations because of a resident’s failure to meet their
responsibility will be viewed as reflecting poorly on the resident’s professionalism.
Clinic managers and attending faculty are require to release any resident from clinical activities in order to meet duty hour
requirements. Any questions may be directed to the program director via email or office visit. These rules are posted on the
ACGME website, www.acgme.org, and on the GME website, www.uthscsa.edu/gme.
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OTHER PROGRAM POLICIES AND PROCEDURES
Absences: Vacation, Sick Leave, and Other Leave
Unplanned Absences:
1. In order to meet our commitment to our patients, we will not cancel or rescheduled FHC patients due to residents’
unplanned absences from their continuity clinic session. We will redistribute patients scheduled to see a PGY1 resident
with an unplanned absence among the residents who are in clinic that session. To accommodate patients scheduled to
see a PGY2 or PGY3 resident with an unplanned absence, the backup resident listed in New Innovations will be called.
If that resident is not available, the Chief Resident will identify an appropriate replacement.
2. If scheduled in the FHC on a day when an unplanned absence is necessary, the resident must notify by phone the clinic
managers (210-358-6511). PGY2 and PGY3 residents must also notify the Chief Resident who will arrange for the FHC
backup to be called in.
3. The resident MUST notify the residency office: (210) 358-3931.
4. If the resident is scheduled to be on a rotation for which backup is needed, then the resident should call a chief
resident immediately (see backup section of policy manual).
5. The residency coordinator will notify the program director, chief residents, and rotation coordinator, as needed.
6. It is inappropriate for residents’ spouses or relatives to call on the residents’ behalf.
7. It is inappropriate to email any unanticipated absences. These absences must be reported by phone.
8. Lack of transportation is NOT a reason for an excused absence. If your vehicle breaks down, you are expected to
arrange alternative transportation to your assigned clinical duty.
9. Upon return, you must come by the residency office and sign a physician leave form ANYTIME you are absent (e.g. jury
duty, funeral leave, sick leave, vacation, USMLE exams, or off-site rotations).
10. Residents are required to attend all scheduled activities on all rotations. Non-attendance at a scheduled activity is
unprofessional and will be reflected in an academic performance evaluation and is subject to disciplinary action.
11. Certain clinical sessions may be required to be made up if deemed necessary by program leadership.
Wednesday Conferences
Wednesday afternoon conferences are required and attendance is expected. Wednesday afternoon is not “free time.” Requests
for time off during Wednesday conference which are not submitted in advance nor due to illness will count as vacation time.
Make-up for conference is at the Program Director’s discretion. Attending required clinics, conferences, and meetings is one of
the ways that you demonstrate your professionalism.
Planned Absences
If any leave plans (i.e. vacation) are requested during Backup or Night Hospital Physician—Home Call it is the resident’s
responsibility to make arrangements to switch with a colleague. The Chief Residents should be notified of all changes to the
published schedules.
Leave Policies
Residents are employees of the University Health System. The Family Medicine Residency uses UHS policies and procedures for
issues related to resident absences from duty and tailors them to the specific requirements for Family Medicine training. As per
the American Board of Family Medicine (ABMF), residents are expected to perform their duties as resident physicians for a
minimum period of eleven months each calendar year. Therefore, absence from the program for vacation, illness, or other
personal leave, must not exceed a combined total of one (1) month per academic year. This translates into the equivalent of 25
work days, which accounts for the standard duty hours requirement of an average of one day off per week and the average
number of days off per rotation in the residency. In addition, this correlates with the 15 vacation days and 10 sick days the
residency allows for each year.
The most important aspect of calculating leave is to ensure that each resident is in training for 11 months of each academic
year to comply with the requirement to sit for the ABFM exam. Typically, one week of vacation is counted as 5 workdays away
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from training. So, a resident taking three individual, non-consecutive weeks of vacation in an academic year is considered away
from training for 15-18 work days, considering that many rotations only offer one day off each week. This leaves room for the up
to 10 individual sick days residents are able to take when necessary without having to extend training. However, if a resident is
on leave for more than one week consecutively, weekend days on either end of the leave as well as those in the middle of the
leave begin to count toward the days away from training. Residents would have to extend their training by one day for each day
over 31 days (the length of a calendar month) away from training. Example: A resident uses three weeks of vacation and two
weeks of sick time consecutively for a maternity leave: vacation from Tuesday 1/1 through Monday 1/21 and sick leave
Tuesday 1/22 through Monday 2/4. Because the leave is consecutive, this counts as 35 days away from training (31 days of
January and 4 days in February). This violates the ABFM requirement that residents are in active training for 11 months of each
academic year. This resident would have to extend residency by 4 days beyond the standard graduation date.
UHS Approved Leave: Approved leave includes the following categories: vacation, sick, specialty meetings and seminars
(including papers/publication presentations), jury duty, military reserves, board and licensure exams, standard and elective
rotations away from University Health System premises, and funeral leave (for spouse, children, mother, father, brother, sister,
mother-in-law, father-in-law, grandmother, grandfather). All scheduled leave must be approved by the University Health System
Professional Staff Services office.
When taking leave there are specific UHS Policies. Unless taking leave for an actual day even if you have no assigned duty you
are consider “on call” as per their policy. So you can get called in as long as it does not violate duty hours. Per UHS, scheduled
days off are still considered ‘on call’ and any resident with a scheduled day off can be called in to a duty assignment as long as
duty hours are not violated.
Specific to our family medicine residency policy, we do delineate a back-up person as likely to be called; however any resident
not on Leave (vacation, sick or funeral), can get called in for back up for emergencies. It would be a rare situation that you
cover a duty when you are not the specific back up resident; however given possible complex situations and unforeseeable
emergencies it is always possible.
When requesting leave you need to arrange any duties that cannot be cancelled (back up etc.) prior to requesting 90 days in
advance. UHS also will not allow a resident to take 5 business days in a row (M-F), with both weekends free from duty.
Therefore, when requesting leave, one weekend will be scheduled as a normal ‘On-Call’ weekend where you should be available
if an emergency arises, and the other will be listed as ‘Leave’ which you are freed of all responsibilities of being a resident
physician. Vacation days will not be charged for weekend Leave unless one of those days is a work day in your rotation;
however, you may be called in to work on any ‘On-Call’ weekend when there is need.
Vacation Leave
UHS House Staff Rules: Vacation benefits for house staff physicians are granted at the rate of ten (10) days with pay for PGY1
level physicians and fifteen (15) days with pay for all other PGY levels. Vacation is scheduled by the specialty department’s
chairperson/program director. Vacation request forms must be submitted to the University Health System Professional Staff
Services office, 30 days prior to the requested vacation leave. All vacation benefits must be taken within the current contract
agreement year. Any exceptions or requests to carry vacation leave into the following contract year must be made in writing by
the specialty department’s chairperson/program director. Unused vacation benefits will not be paid upon termination.
Family Medicine Residency Policy Additional Details: Three (3) weeks of vacation (15 days) per year is allowed and cannot be
carried over except as determined by program and Professional Staff Services. Refer to the backup policy for more details
regarding planned and unplanned absences.
1.
All vacation requests must be submitted in New Innovations (http://www.new-innov.com), no less than 3 months
prior to the start of the month during which vacation is requested.
2.
For PGY3s, vacation is not granted during the last week of residency. No residents may schedule vacation or sick
leave on the last day of an academic year.
3.
Residents may use a maximum of 5 vacation days during vacationable rotations. Weekends (Saturday & Sunday)
do not count against vacation time unless those are normally scheduled work days.
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4.
If a vacation requests spans Monday through Friday, the resident must specify either the weekend before or after
that they want free from all clinical obligations (residents should not expect to be free of all clinical duty over two
weekends).
Holiday Leave
UHS House Staff Rules: UHS does not recognize holidays for house staff. House staff who request leave during holidays (i.e.
Thanksgiving, Christmas, etc.) must utilize their vacation days. They do not automatically receive days off.
Family Medicine Residency Policy Additional Details: Holidays are not entitled days off. If a resident takes a vacation that
precedes, follows, or includes a holiday during which the clinical site is closed, the holidays are not guaranteed off unless that
resident is taking vacation time for that holiday. If the rotation that the resident is on has closed clinics and the resident has not
taken vacation for that holiday time, this is considered “duty in the local area.” Residents not on vacation may be scheduled for
duties in another area if this is needed for holiday coverage or if other residents are unexpectedly unavailable to cover their
clinical obligations due to emergency. If the resident will be travelling or is otherwise unavailable for a weekday holiday, the
holiday will have to be counted as a vacation day since the resident is not available to work. If the holiday ties to a weekend, and
the resident is unable to work the weekend dates if called in for backup, then the weekend will count as vacation dates. New
Innovations will reflect such holidays as “HOL: On Cal,” which stands for “HOLIDAY: ON Call in Local Area.” This reflects the fact
that the Program Director can call the resident in to work if necessary and that the resident is expected to engage in academic
work such as completing Blackboard Assignments, Board Modules, or other studying and scholarly work. Refer to the backup
policy for more details regarding planned and unplanned absences.
When requesting leave on a business day next to a holiday you will be charged vacation for the holiday. Holiday time per UHS is
an On Call assignment and you may be called in. If you want to not be able to be called in you must take vacation that day.
Starting July 1, we will not charge vacation days for weekends tied to holidays. This does not mean that taking a M-F vacation
over a holiday week gives both weekends clear from duties; per UHS policy, one weekend is still considered ‘On-Call’ and the
above rules will still apply. Keep these policies in mind when making vacation plans and general leave requests.
Sick Leave
UHS House Staff Rules: Up to ten (10) days with pay is allowed. Sick leave pay shall be granted only in cases of actual illness.
Time taken off must be cleared with the chairperson/program director. The University Health System Professional Staff Services
office must be notified via the House Staff Physician’s Leave Form when a house staff is on sick leave. House staff may not use
sick leave during their last ten (10) work days unless a physician statement is provided. Information on use of short and long
term disability to cover sick leave/temporary disability (maternity leave included) should be referred to the Benefits Program
sections. Issues related to compensating for leave of absence time (to fulfill specialty board requirements) will be resolved by
the house staff and the department’s chairperson/program director. The University Health System Professional Staff Services
office must be notified, in writing, of any house staff going on leave. Sick leave accrual may be carried over the following
contract year upon the written request by the specialty department’s chairperson/program director.
Family Medicine Residency Policy Additional Details: Up to ten (10) sick days with pay are allowed per year. It is inappropriate
and a violation of your employment agreement to use a sick day as a vacation day. If you call in sick, be prepared to show a
doctor’s excuse upon the program director’s request. Sick leave is granted only in cases of actual illness or for medical
appointments. Residents who wish to use sick leave for a planned appointment (doctor’s appointment, procedure, test, therapy,
dental work, etc.) are required to present a doctor’s note upon return to work. Residents planning any medical or dental care
that requires more than a half-day off may be required to provide advance confirmation of the appointment. Residents may not
use sick leave during their last ten (10) work days unless a physician statement is provided. If all available sick leave is
exhausted and a resident requests leave, residency training may be extended to provide time to complete educational
requirements.
Residents are required to submit a doctor’s excuse for every planned sick day (doctor’s appointment, dental check-up, etc.). A
doctor’s excuse for unplanned sick days may be required at the discretion of the Residency Director. Every planned and
unplanned sick day beyond a total of five sick days will require a doctor’s excuse. Please submit the doctor’s excuse to the
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residency office within one working day of your sick day. Refer to the backup policy for more details regarding planned and
unplanned absences. Residents scheduled as backup may not take a sick day when they are called in for backup.
Maternity/Paternity Leave
UHS House Staff Policy: Requests for maternity/paternity leave must be submitted to Professional Staff Services as soon as
possible after the House Staff begins maternity/paternity leave (preferably within one week) by submitting the University Health
System House Staff leave form. Requests must be accompanied by a memo from the program director including the beginning
date of leave, the expected return date, and the type of leave that will be utilized (i.e. vacation, sick, LOA). The memo must
include the number of days allowed for each type of leave. Once the House Staff has utilized all available vacation and sick
days, he/she will become LOA without pay and will be removed from payroll. House Staff who are married and are in the same
department are eligible to take leave up to 12 weeks total between each of them.
Family Medicine Residency Policy Additional Details: Male residents can use sick leave during the time that their spouse is a
patient in the hospital. After that, they can take as much vacation as they have (up to three weeks). Once they have used their
vacation days, they can take time off based on the FMLA.
Female residents can use as much sick leave as they have remaining, taking into consideration that they may want to reserve
some sick days for future medical appointments of illnesses. After that, they can take as much vacation as they have (up to
three weeks). Once they have used their vacation days, they can take time off based on the FMLA.
Consecutive time away from the residency needs to be within the ABFM requirements of no more than one month away from
training. See above information about how this is calculated.
Please be aware that consecutive weeks off can result in exceeding the ABFM’s 1 month away from residency quickly. Refer to
the backup policy for more details regarding planned and unplanned absences.
Board & Licensing Exams
Family Medicine Residency Policy: Residents are only permitted to take leave to prepare to take exams during the following
rotations:
PGY1s: Ambulatory Pediatrics, Musculoskeletal 1, ER1, GYN, Inpatient Surgery (in place of vacation. No more than 1
week leave)
PGY2s: Ambulatory Procedures, Musculoskeletal 2, Behavioral Science, Outpatient Surgery, Community Medicine,
Electives
PGY3s: Electives, Ambulatory Pediatrics, Family Med3
If residents are taking the ABFM Board Exam in April, they may use up to three of their total CME days as study days for the
ABFM Board Exam during a vacationable month. The Board Exam date is considered a work day and residents will not have to
use leave for this. If residents are on a non-vacationable month in April, they should work with the Chief Residents to ensure
that their clinical duties are covered during that time.
Continuing Medical Education (CME) & Scholarly Activity
Family Medicine Residency Policy: CME& Scholarly Activity days are privileges that are granted to a resident who is on track to
meet the requirements of the Family Medicine Review Committee for patient numbers and weeks per year in the Family Health
Center.
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Five (5) days of CME are permitted each year for residents during their second (PGY2) and third (PGY3) years of
residency. CME days cannot be carried over from year to year.
While PGY1 residents are not specifically given CME days, they may attend the Annual Texas Academy of Family
Physicians C. Frank Webber Lectureship & Family Medicine Residents and Students Conference in Austin, TX as part of
their education if they are in good academic standing, on track to meet the requirements of the Family Medicine Review
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Committee for patient numbers and weeks per year in the FHC, and are on a rotation that is “vacationable” or for which
taking that Friday and Saturday off would not disrupt essential patient care services.
Five (5) days total of scholarly activity days are permitted during the entire duration of the residency training program.
Scholarly Activity time may be used by a resident in order to give a presentation at a conference or meeting.
PGY3s can use up to three (3) CME days to study for the American Board of Family Medicine Certification exam and two
(2) CME days for job interviews (see below).
Residents can use a total of three (3) CME days per year to study for the board exams (ABFM and USMLE3)
Prior approval is required before registering for a conference and/or submitting proposals for presentation at a conference.
1. All requests must be submitted in New Innovations, no less than 3 months prior to the start of the conference.
2. Select either Leave—Conference Attendance OR Leave—Conference Presenter on your request. Please provide details
about the conference in the request.
Job Interviews
PGY3 residents may use two (2) days of Continuing Medical Education (CME) for interviews. To use CME days, all requirements
must be completed on time to ensure that a sound educational experience has occurred. Residents needing more than two
days for interviews will have to use vacation time.
1. Submit completed Interview Preparation Form before the day of the interview (Note: We strongly encourage residents to
be thoughtful about completing this form prior to the interview to be well prepared).
2. Review preparation questions for interview.
3. Write thank you notes for the interview.
Leave requests for job interviews must be made at least 2 weeks in advance of the interview date and should not be confirmed
with the potential employer until it is approved by the residency leadership. The PGY3 resident may have to find backup for
clinical responsibilities on those dates.
Jury Duty
For jury duty, the Residency must have a copy of your jury summons as soon as you receive it so that your clinical duties can be
rearranged. The courts in Bexar County have shown some flexibility have shown some flexibility in allowing physicians
summoned for jury duty to reschedule at a time that is less disruptive to the care of patients. The residents should review their
schedule with the Residency Director or Associate Residency Director to determine if rescheduling is desirable and possible.
Funeral Leave
As per UHS House Staff Policy, three (3) days of funeral leave may be taken for immediate family ONLY (grandparents, parents,
spouse, siblings, children, grandchildren). For all other funeral times, vacation time must be used.
Family & Medical Leave Act (FMLA)
Under the FMLA, residents are eligible for up to twelve weeks unpaid leave for birth or adoption of a child or care of a seriously
ill family member’s personal serious health condition. The FMLA provides leave to care for a newborn child or a child placed in
the employee’s home for adoption or foster care; to care for an employee’s parent, spouse, son, or daughter with a personal
serious health condition; or for a serious personal health condition which prevents the employee from performing his or her job.
For more information, see the GME Policy on Family and Medical Leave (7.3), which can be found on the GME website at
www.uthscsa.edu/gme/gmepolicies.asp.
Leave of Absence
UHS House Staff Policy: A leave of absence will be allowed upon the written request of the chairperson/program director by
submitting to the University Health System Professional Staff Services office a Leave of Absence form 30 days prior to the
beginning date of the physician’s leave. The type (personal, illness, hospitalization/scheduled surgery, etc.) must be specified.
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Should an emergency situation arise, the University Health System Professional Staff Services office must be notified as soon as
possible.
Time-off Request Process
1. Residents must submit ANY planned time-off requests, including: vacation, conferences, meetings, exams, medical
appointments, etc., in New Innovations (www.new-innov.com). Requests should be submitted at least three months in
advance.
a. Planned, non-urgent medical appointments are subject to approval by the residency leadership. In situations
with less than a month’s notice, the resident may be asked to reschedule if the timing of the request interferes
with patient care duties.
b. Time off for job interviews for PGY3 residents must be submitted at least 2 weeks in advance of the interview.
Residents should not confirm the interview date with the potential employer until it is approved by the
residency leadership. The PGY3 resident may have to find back up for clinical responsibilities on those dates. If
changes in call are requested, the PGY3 will usually be required to reciprocate and cover a call for the backup
resident.
2. Requests are received by the Residency Academic Program Coordinator. Approval is based on several factors including:
eligibility, available leave, whether the resident is on a rotation allowing vacation, and if the request has been received
prior to established deadlines.
3. Once the request has been processed by the Program Coordinator, approval or denial is made through New
Innovations. The resident will receive an automated email indicating whether the request was approved or denied.
4. Residents should expect a response within 2 weeks of initial request. If notice is NOT received, the resident should
follow up with the Program Coordinator.
For step-by-step instructions on how to request time off in New Innovations, visit the following link:
http://familymed.uthscsa.edu/residency08/resources/NI_Leave_Requests.pdf
Backup Schedule
The backup schedule is designed to help cover for colleagues who are unavoidably absent. It is designed for use under dire
circumstance ONLY. Using the backup system to attend doctor/dentist appointments or anything that does not involve serious
illness (i.e. flu virus, etc.) is unprofessional and will not be tolerated. The Chief Residents will monitor the use of the backup
schedule to ensure that it is used fairly and appropriately.
Backup will be called in to cover essential rotations. Essential rotations include, but are not limited to:
o PGY2: IPS, Geri IPS, NHP, Inpatient Pedi, OB
o PGY3: IPS, Geri IPS, NHP, MatSr In addition to these essential rotations, backup will be called for any rotation
that schedules patient panels—Outpatient Surgery, VA Cardiology Clinic, etc.
FHC panels will have backup called in as needed.
PGY2 and PGY3 residents will be scheduled for “Essential Backup” rotations throughout the year. The backup rotations are:
o PGY2: Elective Rotation (Essential Backup—including 1st and 3rd weekends of the rotation) and Ambulatory
Procedures (Backup 2nd and 4th weekends of the rotation).
o PGY3: Backup Elective (Essential Backup—including 2nd and 4th weekends of the rotation) and EEU (Backup
1st and 3rd weekends).
All weekend backup begins 6pm on Friday night, for all three PGY groups.
Residents not listed as essential backup, who are on non-essential rotations, can still be called for backup if this is necessary
(i.e. if multiple residents are absent at the same time). The Chief Residents will always call the essential backup residents first,
before calling residents who are on non-essential rotations. The Chief Residents will monitor the use of the backup schedule to
make sure the same resident is not getting called in too many times, so as not to adversely affect the resident’s learning.
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If backup is required due to a sick day, the resident who was absent from his or her assignment will be required to bring in a
doctor’s note. If the resident fails to provide a doctor’s note, he or she will be asked to make up the missed assignment for sick
days called in at the last minute.
If you are the official back up you must answer your page or phone within 20 min, and you need to be immediately available (at
your assignment within 1 hour) in the city of San Antonio. Starting July 1, there are new rules & penalties (clinical and
administratively) if you are the official backup and you are not immediately available.
If you are not the official back up but have an “on call” assignment you need to be able to return shortly to San Antonio. An
acceptable time frame would be at the place of required duty within 2 hours. The new rules and penalties for the official backup
do NOT apply to you, but we ask that you respect the team and answer any calls you get on the weekends, as they may be in
regards to an emergency.
If you call in sick on a business day next to a vacation or a holiday you will need to provide a note. If no note is provided you will
be charged a vacation day and have to make up any missed assignment at the discretion of program director and chiefs. Please
be aware that it is possible to use more than your allowed vacation days, and be required to extend your residency if this
happens.
The Program Director has the final say on what assignments require Backup.
Benefits
Residents are employees of the University Health System (UHS). Benefits are provided in accordance with UHS policies. Se the
website for more information: http://www.universityhealthsystem.com/benefits.
Additional benefit information and hospital policies can be reviewed on the Graduate Medical Education (GME) website:
http://www.uthscsa.edu/gme/hospitalpolicies.asp.
Licensure
Third year residents are required to obtain a state license where they intend to practice by December 31st of their third year.
Resources:
Texas Medical Board: http://www.tmb.state.tx.us
USMLE: www.usmle.org
Moonlighting
GME General Policy: Moonlighting is defined as compensated clinical work performed by a resident during the time that he/she
is a member of a residency program. PGY1 residents (interns) and residents on J-1 visas cannot moonlight.
The Graduate Medical Education Committee and the UTHSCSA-sponsored graduate medical education (GME) programs are
responsible for ensuring a high quality learning environment for the residents, notably by ensuring a proper balance between
education and patient care activities within duty hour limitations as prescribed by the ACGME Institutional and Program
Requirements. Because of these concerns, moonlighting is, in general, discouraged for residents in ACGME-accredited
programs sponsored by UTHSCSA. During residency training, the resident’s primary responsibility is to acquisition of
competencies associated with their specialty.
Moonlighting is a privilege, not a right. Residents are not required to engage in moonlighting.
Under special circumstances, a resident may be given permission by his or her Program Director to engage in moonlighting. In
such cases, the moonlighting workload must not interfere with the ability of the resident to achieve the goasl and objectives of
his or her GME program,
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Moonlighting—the compensated clinical work that is not part of the residency program. UTHSCSA does not provide professional
liability coverage for external moonlighting. Without compromising the goals of resident training and education, a program
director may allow a resident to moonlight if all of the following conditions are met:
• The responsibilities in the moonlighting circumstance are delineated clearly in writing (using the Moonlighting
Documentation form—see appendix. The form can also be found on the GME website at
http://uthscsa.edu/gme/documents/6.4.1MoonlightingDocumentationForm-2012-10.pdf) and are prospectively
approved in writing by the Program Director.
• The resident is not on probation or administrative status.
• The written documentation of the moonlighting activity is filed with resident records and is available for GME Committee
monitoring.
• The moonlighting workload is such that it does not interfere with the ability of the resident to achieve the goals and
objective of the GME program.
• The moonlighting does not place the resident in jeopardy of violating any of the current ACGME and specialty-specific
Duty Hours Standards.
• The moonlighting opportunity does not replace any part of the clinical experience that is integral to the resident’s
training program.
• The resident is licensed for unsupervised, independent medical practice in the state where the moonlighting will occur.
• The resident’s performance in the training program will be monitored for the effect of moonlighting on the resident’s
level of fatigue. Adverse effects will lead to withdrawal of permission to engage in moonlighting.
• Moonlighting activities should adhere to all duty hours standards and be logged in New Innovations.
In addition, the resident considering moonlighting should seek written assurance of professional liability (including “tail”
insurance), and workers’ compensation coverage from any outside employer. Professional liability insurance is provided by the
UT System Medical Liability Self-Insurance Plan only for the activities that are an approved component of the training program.
There is NO coverage for professional activities outside of the scope of the residency program.
Family Medicine Moonlighting Policy: Per ACGME requirements, PGY1 residents are not permitted to moonlight. Moonlighting is
permitted for PGY2/PGY3 residents with prior approval by the Program Director. It must not interfere with the ability of the
resident to achieve the goals and objectives of the educational program. Moonlighting is considered part of the 80-hour weekly
limit on duty hours.
Prior to moonlighting, you are required to notify the Program Director of the intent to moonlight. The program monitors the
effects of moonlighting both in duty hour logs and through discussions at Core Faculty meetings. Residents on probation or
administrative status are prohibited from moonlighting. The program reserves the right to prohibit or limit moonlighting hours, if
in the opinion of the Program Director, the moonlighting activities are interfering with program educational activities.
The primary responsibility for each resident is to meet the educational requirements of training. At no time will any moonlighting
resident pay another resident to cover his/her call so they can go to a moonlight job. Any infraction of this rule will result in
immediate suspension of moonlighting privileges and may result in other disciplinary actions up to and including termination
from the program for both residents involved.
No clinic or rotation may be cut short to leave early to a moonlight job.
Any resident scoring more than one standard deviation from the PGY mean scaled score will NOT be given permission to
moonlight.
Electives
1. Requests for ALL ELECTIVES must be submitted three (3) months prior to the start of the rotation.
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2. If an elective request is not submitted by the above deadline, the resident may be assigned to clinic for the entire
rotation.
3. No atypical or non-clinical electives, including all “reading electives,” will be approved after the above deadline, except
when it is the Program Director’s judgment that such an elective is required for the resident’s educational progress, in
which case its content will be determined by the Program Director.
4. The Program Director may require modifications to the proposal before final approval. It is required that requests be
submitted well before—preferably a month before—the final deadline. In the case of atypical electives (including all
“reading electives”), this is particularly important. Residents are advised to consult the following Reading Electives
policy in preparing their request and should make sure all items are addressed prior to submission.
5. Residents are not allowed to receive a stipend or other payment for work done as part of an elective experience.
Away Electives
1. AWAY electives will be approved only for educational experiences which cannot be obtained in San Antonio. To be
eligible to do an away elective, conference attendance must meet established standards, and the resident must be in
compliance with all administrative requirements. Residents on Administrative Status or Probation are not eligible for
away electives.
2. No more than one AWAY elective may be taken during the third year of residency.
3. An away reading elective may be considered in circumstances in which true hardship can be demonstrated. Residents
must be able to meet RRC requirements for patient visits and weeks in the Family Health Center if an away elective is
to be considered for this reason.
4. PGY3 residents are not permitted to take an AWAY elective during the last two weeks of residency.
5. Away electives for PGY2 residents may be approved by the program director for special circumstances.
Reading Electives
1. Reading electives may be approved by the program director on an individual basis in extenuating circumstances. The
requirements for a reading elective, if approved are:
a. Develop an individual learning plan with a specific set of goals and objectives.
b. Produce a final produce, such as a paper for publication or a formal presentation for a conference or Grand
Rounds.
c. Find a faculty member to serve as your supervisor on the required final product.
d. Attend four (4) FHC sessions per week.
Dress Code
Dress in Family Medicine Outpatient Clinical Settings:
Physicians are expected to wear appropriate attire when seeing patients in the Family Health Center and Family Medicine
ambulatory clinic settings such as Well Child Clinic, Bone & Joint Clinic, Procedures Clinic, etc. Residents are required to dress in
the manner that would be expected of a primary care physician seeing patients in any office-based practice (business dress). It
is important to portray a professional demeanor in appearance and action. Attire that would be inappropriate in a private office
is inappropriate in our setting. Attire should protect the physician’s modesty and avoid embarrassing patients and coworkers.
At a minimum, men should wear a dress shirt with tie and slacks. Comparable dress is expected for women. Men are excused
from wearing a tie during FHC Procedures (excision & vasectomy) Clinic, Well Child Clinic, and during Pedi Walk In clinic
sessions. Shorts, T-shirts, blue jeans, sweats, and scrubs are inappropriate attire. Blouses/shirts must be long enough to cover
the entire abdomen. “Short pants,” such as capris, must fall below the knee. Tattoos must not be visible. Closed-toe shoes
must be worn at all times—sandals or open-toe shoes should not be worn in any clinical settings, particularly where there is the
possibility of contact with blood/bodily fluids or sharps. If physicians doing procedures in the FHC wish to wear scrubs, locker
rooms are available in the clinic for changing into scrubs.
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From Memorial Day through September 30, Men are not required to wear a tie. They must wear a shirt with a collar (dress shirt
or polo shirt styles). Dress for women should be comparably professional. In the FHC, the following exclusions apply: No T-shirts,
no jeans, no scrubs, no sneakers, and no open-toe shoes in the clinic. Residents attending a meeting with participants from
other departments (e.g. GMEC meetings) should conform to the usual shirt/tie dress code. Residents are also required to
conform to the dress code of the service they are rotating on, if the dress code for that department or clinic is more restrictive.
Residents on Inpatient Services may wear scrubs. Street clothes should be covered with a clean, white lab coat when on the
wards. If you choose to wear scrubs on the wards, the tops and bottoms should match (i.e., no polo shirts with scrub bottoms or
slacks with scrub tops). Sneakers/running shoes may be worn with scrubs.
Dress in Other Settings
All residents will wear clean scrubs while on duty for Night Hospital Physician and while on Maternity Service.
While on the Inpatient Service, the UHS dress code will be applied for all residents. All residents/interns will wear their clean,
white lab coat (for males, with tie) if not in scrubs.
Directors of individual clinics may set additional dress requirements with which physicians practicing in those settings must
comply. Residents should comply with the dress requirements of their host service when rotating with another department of
practice.
Dress code must be adhered to at all times. Discrepancies will be documented as lack of professionalism.
Conference Attendance
Attendance at mandatory conferences and meetings is required professional behavior of resident physicians. Attendance at all
Wednesday afternoon conferences is mandatory for all residents not on leave or an away elective. Wednesday afternoon is not
“free time.” Requests for time off during Wednesday conferences which are not submitted in advance nor due to illness will
count as vacation time. Exceptions can only be made when the Program Director or Associate Program Director has specifically
excused a resident for cause. Make-up for the conference is at the Program Director’s discretion.
Attendance for each session will be monitored, primarily through the use of the sign-in list for each session. Residents are
responsible for signing in at each conference in order to receive credit for attending. If a resident fails to sign in for conference
and has not been otherwise excused they will be considered absent and vacation time will be deducted equal to time missed.
This type of behavior is considered a professional breach and will be documented in the resident’s file and addressed by the
Clinical Competency Committee.
Chief Resident Elections
Chief Resident Elections occur each year during the January to April timeframe. There are two Chief Resident slots. The Program
Director has the discretion to modify the selection process. Below are the general guidelines:
Nominations: Residents may self-nominate. Only current PGY2s are eligible for election.
Chief Speeches: Each candidate is given the opportunity to make a speech during a Wednesday residency conference.
Voting: Each current resident has two votes.
The program occasionally needs a resident to serve as Academic/Teaching Chief. This position is selected by the residency
leadership.
Use of Internet and Social Networking Sites
(UTHSCSA GME Policy 5.2)
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Social and business networking websites (LinkedIn, Facebook, Twitter, Instagram, Tumblr, Pinterest, YouTube, and others) are
increasingly used for communication. The purpose of this policy is to provide guidance to residents regarding appropriate use of
social networking sites.
Guiding Principles
•
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•
•
•
•
•
•
•
•
Physicians’ professional images are important and should be protected. Portrayal of unprofessional behavior may
impair a physician’s ability to effectively practice medicine, become licensed, and participate in positions of trust and
responsibility in the community.
Internet use must not interfere with the timely completion of educational and clinical duties. Personal blogging or
posting of updates should not be done during work hours or with institutional computers.
All material published on the web should be considered public and permanent.
Residents should expect no privacy when using institutional computers.
The individual is responsible for the content of hi/her own blog/posts, including any legal liability incurred (HIPAA or
other).
Avoid discussing any sensitive, proprietary, confidential, private health information or financial information about the
institutions (including but not limited to UTHSCSA and the affiliated health systems). Any material posted by a resident
that identifies an institution in which the resident is working should have prior written authorization by the appropriate
offices of that institution.
The tone and content of all electronic conversations should remain professional. Respect among colleagues and
coworkers must occur in a multidisciplinary environment.
Refrain from posting any material that is obscene, defamatory, profane, libelous, threatening, harassing, abusive,
hateful or embarrassing to another person or any other entity.
Privacy and confidentiality between physician and patient is of the utmost importance. All health care providers have an
obligation to maintain the privacy of patient health information as outlined by the Health Insurance Portability and
Accountability Act (HIPAA).
It is inappropriate to “friend” patients on any social networking site or to check patient profiles.
Patient Information:
Identifiable protected health information (PHI) should never be published on the internet. This applies even if no one other than
the patient is able to identify him/herself from the posted information. Residents must adhere to all HIPAA principles. Patient
images should be obtained only with written consent, and then only on institutional hardware, and never on residents’ personal
equipment. Electronic transmission of such images must be transmitted only on institutional hardware, and never on residents’
personal equipment.
Communication Regarding Hospitals or the University
Unauthorized use of institutional (including but not limited to UTHSCSA and the affiliated health systems) information or logos is
prohibited. No phone numbers, email addresses, or web addresses may be posted to a website without permission from an
authorized institutional individual.
Offering Medical Advice
It is never appropriate to provide medical advice on a social networking site.
Privacy Settings
Residents should consider setting privacy at the highest level on all social networking sites.
In light of rapid change, it is envisioned that this policy will required revision at intervals.
Failure to follow these guiding principles may be considered a breach of professionalism, resulting in any and all consequences
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deemed appropriate by the individual’s program and leadership.
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Policy No. 4.13
Page Number 1 of 4
Effective Date: 06/28/11
TITLE: PERSONAL USE OF SOCIAL MEDIA
PURPOSE:
To provide all University Health System (Health System) employees and authorized users of Health
System information assets with requirements for participation in social media, including Health
System- hosted social media, and non-Health System social media, through which an employee’s
Health System affiliation is known, identified, or presumed. [Key words: Protected Health Information
(PHI), privacy, social media, disclosure, integrity.]
POLICY STATEMENT:
The Health System acknowledges and respects the right of employees to use social media on their personal time
and using personal electronic devices. Social media access through Health System-owned equipment, however, is
for business purposes only and is restricted. This policy establishes boundaries for employees as they create and
use personal social networking technologies.
POLICY SCOPE:
The lack of explicit reference to specific social media and attendant communications does not limit the scope of
this policy. Where no explicit policy statement exists, employees should use their professional judgment and take
the most prudent action possible regarding use of social media. Employees are encouraged to consult with the
Corporate Communications & Marketing Department if they have any questions.
In publishing this policy, the Health System is not assuming duty to monitor social media or other public
communications, but reserves the right to take appropriate action in accordance with this policy at its sole
and absolute discretion.
Social media access through Health System-owned equipment is restricted to the Corporate Communications &
Marketing and Information Assets departments, and other authorized, contracted users.
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Policy No. 4.13
Page Number 2 of 4
Effective Date: 06/28/11
POLICY ELABORATION:
DEFINITIONS
A.
Blog -A website that allows an individual or group of individuals to share personal
commentary, observations and opinions with online audiences.
B.
Podcast – A collection of digital media files distributed over the Internet, often using syndication
feeds, for playback on portable media players and personal computers.
C.
Protected Health Information (PHI) – Any information, whether oral, written, electronic or recorded, in
any form or medium (including demographic information collected from an individual) that identifies or
may be used to identify the individual and that relates to
1. The past, present or future physical or mental condition of an individual;
2. The provision of health care to an individual; or
3. The past, present or future payment for the provision of health care to an individual.
D. Social Media – Any tool or service that uses the Internet to facilitate conversations or provide a forum
for discussion. Social media includes items such as blogs, photo and video galleries, podcasts,
discussion forums and social networks. Current examples include Facebook, MySpace, Twitter,
LinkedIn, YouTube, and Flickr.
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Policy No. 4.13
Page Number 3 of 4
Effective Date: 06/28/11
II. INFORMATION AND REQUIREMENTS REGARDING REFERENCE TO THE HEALTH SYSTEM THROUGH PERSONAL
SOCIAL MEDIA
A. Personal blogs and social media pages containing content about the Health System must have clear disclaimers to
indicate that the employee is speaking for him/herself and not on behalf of the Health System.
B. All communications should be written in the first person. C.
Health System logos and trademarks may not be used.
D. Employees must respect copyright laws, and reference or cite sources appropriately.
E. The privacy of patient information is paramount. In all cases, patient PHI and patient images must never be
published. Information published on blogs and social media pages must comply with Policy No. 2.03, Release
of General and Patient Information, as well as Policy No. 2.1401, Uses and Disclosures of Patient Health
Information.
F. Disclosure of Health System confidential or proprietary information is expressly prohibited.
G. Health System clients, contractors, partners or suppliers may not be identified by name. Confidential details
regarding their business relationships or activities with the Health System may not be discussed without prior
written permission.
H. Employees are prohibited from blogging or posting on personal sites while at work, according to Policy No.
2.08.02, Information Asset Security/Use.
I.
Employees may not use their Health System email addresses (@uhs-sa.com) for personal blogs and social
networking on personal or other non-Health System hosted sites.
J.
Employees’ online postings do reference or contain content about the Health System must be consistent with
the Health System’s mission, vision, values and/or brand. Employees are prohibited from posting anything
obscene, vulgar,or defamatory, threatening, discriminatory, harassing, abusive, hateful or embarrassing to or
about fellow employees.
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Policy No. 4.13
Page Number 4 of 4
Effective Date: 06/28/11
III. POLICY VIOLATIONS
A. Users encountering violations of this policy should immediately report the incident to their
supervisors and/or the Integrity Office. Information Services should be notified immediately in cases
where assets may be at risk. The supervisor is responsible for notifying the Integrity Office if the
violation was not reported.
B. Each incident will be reviewed on an individual basis and, where appropriate, the supervisor may
need to contact Human Resources and take disciplinary action, up to and including termination of
the employee. In addition, Information Services may revoke access to computer systems assets if
the violation is determined to put such resources at risk.
C. Violations of state and federal laws may subject persons to penalties of fines or imprisonment or
both. The Health System reserves the right to pursue legal action as appropriate.
REFERENCES:
Corporate Policy No. 2.03, Release of General and Patient Information,
Corporate Policy No. 2.08.02, Information Asset Security/Use
Corporate Policy No. 2.1, Integrity Program
Corporate Policy No. 2.14.01, Uses and Disclosures of Protected Health Information
University Health System Employee Handbook
OFFICE OF PRIMARY RESPONSIBILITY:
Vice President, Strategic Communications & Patient Relations
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Physician in Training (PIT) Permit
June 12, 2009
To:
Physician in Training (PIT) Permit Holders
From:
Texas Medical Board, Licensure Division - Physician in Training Section
Subject: PIT Holder Reports
Board rule §171.5 states in part that each PIT holder shall report in writing to the Executive Director of the Board, the following
events within thirty days of their occurrence.
§171.5. Duties of PIT Holders to Report.
(a) Failure of any PIT holder to comply with the provisions of this chapter or the Medical Practice Act §160.002
and §160.003 may be grounds for disciplinary action as an administrative violation against the PIT holder.
(b) The PIT holder shall report in writing to the executive director of the board the following circumstances
within thirty days of their occurrence:
(1) the opening of an investigation or disciplinary action taken against the PIT holder by any licensing
entity other than the TMB;
(2) an arrest, fine (over $250*), charge or conviction of a crime, indictment, imprisonment, placement
on probation, or receipt of deferred adjudication; and
(3) diagnosis or treatment of a physical, mental or emotional condition, which has impaired or could
impair the PIT holder's ability to practice medicine.
*This amount is currently $100 in rule, but it in the process of being changed to $250. Report only fines over $250.
You may use the form on the following page to make a report. The contact information for the Board is at the bottom of the
page.
Location Address:
333 Guadalupe, Tower 3, Suite 610
Austin, Texas 78701
Mailing Address
P.O. Box 2029
Austin, Texas 78768-2029
www.tmb.state.tx.us
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Phone 512.305.7030
Fax 512.463-9416
Licensure Fax 512.305.7009
PHYSICIAN IN TRAINING PERMIT HOLDER’S REPORT
Name:
TMB Personal ID Number:
(Please type or print name as it appears on permit)
_________
_________
Social Security #:
_________
Permit Number:
________
Training program name, address and specialty:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
E-Mail Address:
________
Date of Event/Action:
_______
Please furnish specific details and/or reasons for the report, including specific dates and/or changes. If more room is needed,
please use the reverse side of this form. You may be asked to furnish more information after Board staff has reviewed your
report. Thank you.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
_________________________________________________________________
Signature
____________________________________
Date
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Requirements
ACGME Program Requirements:
Common Program Requirements:
http://www.acgme.org/acgmeweb/tabid/429/ProgramandInstitutionalAccreditation/CommonProgramRequirements.aspx
Family Medicine Policies: http://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/120pr07012007.pdf
General Information:
http://www.acgme.org/acgmeweb/tabid/132/ProgramandInstitutionalAccreditation/MedicalSpecialties/FamilyMedicine.aspx
UT Health Science Center at San Antonio, Graduate Medical Education Office Institutional Requirements
http://uthscsa.edu/gme/policies.asp
American Board of Family Medicine Residency Requirements
https://www.theabfm.org/cert/guidelines.aspx
American Board of Family Medicine Requirements for Maintenance of Certification
https://www.theabfm.org/moc/index.aspx
Texas Medical Board
http://www.tmb.state.tx.us/
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